TAX ID|NPI|SERVICES|Description|DRG BASE RATE/STOP LOSS|RATES|REVENUE CODES|DISCOUNT|NOTES
823914925|1316938459|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.
823914925|1316938459|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.
823914925|1316938459|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.
823914925|1316938459|Outpatient|All Other Services||||65% of billed charges|All other services 65% discount - 35% allowance. Rates are lesser of billed charges or Fee Schedule.