TAX ID|NPI|SERVICES|Description|DRG BASE RATE/STOP LOSS|RATES|REVENUE CODES|DISCOUNT|NOTES
58-2149128|1043270564|Inpatient|All Inpatient|DRG rate applies - base $12360.00|Reference Tab TIN 582149128 DRG Domestic |||"Reference current fiscal year CMS DRG Weight Table. DRG table will be updated annually| consistent with the annual CMS update (October of each year). Rates are Lesser of billed charges or Fee Schedule."
58-2149128|1043270564|Inpatient|All Inpatient |Stop loss applies to all Inpatient DRG Claims/Threshold $70000.00|||30%|30% of charges after Stop loss Threshold. Rates are Lesser of billed charges or Fee Schedule.
58-2149128|1043270564|Outpatient|ASP Rates||Reference Tab TIN 582149128 ASP Domestic|636|100% of ASP|Effective 10.1.2016 ASP rates will be updated annually (Oct 1 of each yr) using the ASP file rates effective July 1st of each year. If  pharma/drgu code billed is not found on the ASP file then reimbursed at 65% discount of the the billed amount. Rates are Lesser of billed charges or Fee Schedule.
58-2149128|1043270564|Outpatient|All Other Services||||65% of billed charges|All other services 65% discount - 35% allowance. Rates are lesser of billed charges or Fee Schedule.