Tax ID|NPI|SERVICE|DESCRIPTION|DRG BASE RATE|DRG  BASE RATE|REVENUE CODES|CPT CODE|CASE RATES|PAYMENT TERMS|PAYMENT PERCENTAGE|OP SURG ASC CATEGORY GROUPINGS|Grouping Number|OP SURG GROUPER RATES|NOTES
71-1045290|1962435792|Inpatient|All Inpatient Services|DRG applies - Base Rate $12 654.00|See Tab TIN 71-1045290 DRG Rates for allowances|||||||||
71-1045290|1962435792|Inpatient|Supplies|||274 275 276||INCLUDED IN DRG RATE||||||
71-1045290|1962435792|Inpatient|Implants|||278||INCLUDED IN DRG RATE||||||
71-1045290|1962435792|Inpatient|High Cost Drugs|||636||INCLUDED IN DRG RATE||||||
71-1045290|1962435792|Observation ||||760  762||$4|371.00 Case Rate||||||When case rate is involved| the ONLY other line items paid with these services will be Implants and High Cost Drugs.
71-1045290|1962435792|ER Case Rate|Level 1||||99281|678.00||||||Rates are all-inclusive; no additional reimbursement for Lab and Radiology services. When a case rate is involved| the ONLY other line items paid with these services will be Implants and High Cost Drugs.
71-1045290|1962435792|ER Case Rate|Level 1||||99282|678.00||||||Rates are all-inclusive; no additional reimbursement for Lab and Radiology services. When a case rate is involved| the ONLY other line items paid with these services will be Implants and High Cost Drugs.
71-1045290|1962435792|ER Case Rate|Level 2||||99283|1115.00||||||Rates are all-inclusive; no additional reimbursement for Lab and Radiology services. When a case rate is involved| the ONLY other line items paid with these services will be Implants and High Cost Drugs.
71-1045290|1962435792|ER Case Rate|Level 2||||99284|1115.00||||||Rates are all-inclusive; no additional reimbursement for Lab and Radiology services. When a case rate is involved| the ONLY other line items paid with these services will be Implants and High Cost Drugs.
71-1045290|1962435792|ER Case Rate|Level 3||||99285|1748.00||||||Rates are all-inclusive; no additional reimbursement for Lab and Radiology services. When a case rate is involved| the ONLY other line items paid with these services will be Implants and High Cost Drugs.
71-1045290|1962435792|ER Case Rate|||||Unlisted Codes|50% Discount||||||For ER Case Rated codes not listed in the agreement| example 99291| claims should pay at All Other OP Percent of Charge reimbursement.
71-1045290|1962435792|Inpatient|Medstop Case Rate||||99211|218.00||||||Rates are all-inclusive; no additional reimbursement for Lab and Radiology services. When a case rate is involved| the ONLY other line items paid with these services will be Implants and High Cost Drugs.
71-1045290|1962435792|Inpatient|Medstop Case Rate||||99212|218.00||||||Rates are all-inclusive; no additional reimbursement for Lab and Radiology services. When a case rate is involved| the ONLY other line items paid with these services will be Implants and High Cost Drugs.
71-1045290|1962435792|Inpatient|Medstop Case Rate||||99213|218.00||||||Rates are all-inclusive; no additional reimbursement for Lab and Radiology services. When a case rate is involved| the ONLY other line items paid with these services will be Implants and High Cost Drugs.
71-1045290|1962435792|Inpatient|Medstop Case Rate||||99214|218.00||||||Rates are all-inclusive; no additional reimbursement for Lab and Radiology services. When a case rate is involved| the ONLY other line items paid with these services will be Implants and High Cost Drugs.
71-1045290|1962435792|Inpatient|Medstop Case Rate||||99215|218.00||||||Rates are all-inclusive; no additional reimbursement for Lab and Radiology services. When a case rate is involved| the ONLY other line items paid with these services will be Implants and High Cost Drugs.
71-1045290|1962435792|Inpatient|Radiology - MRI (PER SCAN)|||610-619||847.00||||||Effective 1.1.2021| when MRI and CT services are received| any additional charges on the claim are to be payable under the agreement category All Other Outpatient Percent of Charge| in addition to the applicable per scan agreement rate. Although not an all-inclusive list| the following revenue codes (250 255 258 260 335 481) should be included for the All Other Percent of Charge reimbursement
71-1045290|1962435792|Inpatient|Radiology - CT (PER SCAN)|||350-359||602.00||||||Effective 1.1.2021| when MRI and CT services are received| any additional charges on the claim are to be payable under the agreement category All Other Outpatient Percent of Charge| in addition to the applicable per scan agreement rate. Although not an all-inclusive list| the following revenue codes (250 255 258 260 335 481) should be included for the All Other Percent of Charge reimbursement
71-1045290|1962435792|Inpatient|Other Radiology|||320-329 340-342 349 400-409||||||||Reference TIN 71-1045290 Radiology Tab for Final Fee
71-1045290|1962435792|Inpatient|Laboratory|||300-319||||||||Reference TIN 71-1045290 Lab Tab for Final Fee
71-1045290|1962435792|Outpatient|Outpatient Surgery|||||||||||Additive Implants and High Cost Drugs will be reimbursed as outined below (lines 26 to 29)
71-1045290|1962435792|Outpatient|Outpatient Surgery|||360 & 361|||1st  Procedure|100%||||
71-1045290|1962435792|Outpatient|Outpatient Surgery|||360 & 361|||2nd Procedure |50%||||
71-1045290|1962435792|Outpatient|Outpatient Surgery|||360 & 361|||3rd  Procedure|25%||||
71-1045290|1962435792|Outpatient|Outpatient Surgery|||360 & 361|||All Other Procedures|25%||||
71-1045290|1962435792|Outpatient Surgery|Implants|||278|||Billed Charges|80%||||Based on revenue code| not line items only
71-1045290|1962435792|Outpatient Surgery|Implants|||278|||Threshold|500.00 ||||Total Billed Charges
71-1045290|1962435792|Outpatient Surgery|High Cost Drugs|||636|||Billed Charges|80%||||Based on revenue code| not line items only -
71-1045290|1962435792|Outpatient Surgery|High Cost Drugs|||636|||Threshold|500.00 ||||Total Billed Charges
71-1045290|1962435792|Outpatient Surgery|Supplies|||274 275 276||||Included in Outpatient Payment||||
71-1045290|1962435792|Outpatient Surgery|All Other Outpatient Percent of Charge|||||||50% of billed charges (50% Discount)||||
71-1045290|1962435792|Outpatient|Outpatient Surgery ASC|||360 & 361|||||Ungrouped|00|4371.00|
71-1045290|1962435792|Outpatient|Outpatient Surgery ASC|||360 & 361|||||ASC Category 1|01|2328.00|
71-1045290|1962435792|Outpatient|Outpatient Surgery ASC|||360 & 361|||||ASC Category 2|02|3037.00|
71-1045290|1962435792|Outpatient|Outpatient Surgery ASC|||360 & 361|||||ASC Category 3|03|3748.00|
71-1045290|1962435792|Outpatient|Outpatient Surgery ASC|||360 & 361|||||ASC Category 4|04|4458.00|
71-1045290|1962435792|Outpatient|Outpatient Surgery ASC|||360 & 361|||||ASC Category 5|05|5169.00|
71-1045290|1962435792|Outpatient|Outpatient Surgery ASC|||360 & 361|||||ASC Category 6|06|5878.00|
71-1045290|1962435792|Outpatient|Outpatient Surgery ASC|||360 & 361|||||ASC Category 7|07|6589.00|
71-1045290|1962435792|Outpatient|Outpatient Surgery ASC|||360 & 361|||||ASC Category 8|08|7299.00|
71-1045290|1962435792|Outpatient|Outpatient Surgery ASC|||360 & 361|||||ASC Category 9|09|8010.00|
71-1045290|1962435792|Outpatient|Outpatient Surgery ASC|||360 & 361|||||ASC Category 10|10|8720.00|
||||||||||||||Hierarchy of Reimbursement
71-1045290|1962435792|Inpatient/Outpatient/ER/Outpatient Surgery /Observation/ASC /Medstop/Laboratory/ Radiology||||||||||||Reimbursement when transfer from ER to Inpatient occurs  Inpatient rates will apply.
71-1045290|1962435792|Inpatient/Outpatient/ER/Outpatient Surgery /Observation/ASC /Medstop/Laboratory/ Radiology||||||||||||Reimbursement when transfer from Observation to Inpatient occurs  Inpatient rates will apply.
71-1045290|1962435792|Inpatient/Outpatient/ER/Outpatient Surgery /Observation/ASC /Medstop/Laboratory/ Radiology||||||||||||Reimbursement when transfer from Ambulatory Surgery and Outpatient Surgery to Inpatient  Inpatient rates will apply.
71-1045290|1962435792|Inpatient/Outpatient/ER/Outpatient Surgery /Observation/ASC /Medstop/Laboratory/ Radiology||||||||||||For Ambulatory Surgery and Outpatient Surgery with Observation| ASC rates apply.
71-1045290|1962435792|Inpatient/Outpatient/ER/Outpatient Surgery /Observation/ASC /Medstop/Laboratory/ Radiology||||||||||||Reimbursement when transfer to Observation occurs  Observation rate will apply.
71-1045290|1962435792|Inpatient/Outpatient/ER/Outpatient Surgery /Observation/ASC /Medstop/Laboratory/ Radiology||||||||||||For ER services with transfer to Ambulatory Surgery and Outpatient Surgery  ASC rates apply.
71-1045290|1962435792|Inpatient/Outpatient/ER/Outpatient Surgery /Observation/ASC /Medstop/Laboratory/ Radiology||||||||||||For MedStop services with transfer to ER  ER rates will apply.
71-1045290|1962435792|Inpatient/Outpatient/ER/Outpatient Surgery /Observation/ASC /Medstop/Laboratory/ Radiology||||||||||||Any Laboratory or Radiology codes billed  but not included n the respective laboratory or radiology fee schedulse (TIN 71-1045290 Radiology 2022 or TIN 71-1045290 Laboratory 2022) will be reimbursed at 50% of billed charges.
71-1045290|1962435792|Inpatient/Outpatient/ER/Outpatient Surgery /Observation/ASC /Medstop/Laboratory/ Radiology||||||||||||MRI and CT services will be reimbursed on a per scan basis with multiple procedures reimbursed at 100% for the 1stm abd 50% for each and eery procedure thereafter.
71-1045290|1962435792|Inpatient/Outpatient/ER/Outpatient Surgery /Observation/ASC /Medstop/Laboratory/ Radiology||||||||||||Any pre-op testing included on the Ambulatory Surgery and Outpatient Surgery claim will be combined with the surgery claim.