TAX ID|NPI|SERVICES|REV CODE|PER DIEM RATE|DISCOUNT|OUTPATIENT CATH CPT CODES|OUTPATIENT CATH RATES|MS-DRG CODE|CARDIAC CASE RATE|NOTES
58-2149128|1043270564|INPATIENT|Medical|$1|000.00 ||||||
58-2149128|1043270564|INPATIENT|SURGICAL |$1|300.00 ||||||
58-2149128|1043270564|INPATIENT|ICU|$1|900.00 ||||||
58-2149128|1043270564|INPATIENT|173|$1|900.00 ||||||If any claim contains an ICU code| the entire bill should be paid at ICU rate
58-2149128|1043270564|INPATIENT |174|1|900.00||||||If any claim contains an ICU code| the entire bill should be paid at ICU rate
58-2149128|1043270564|INPATIENT|MATERNITY/OB||30%|||||30% Discount from billed charges
58-2149128|1043270564|INPATIENT|WELL BABY (1 or 2 day)|$300.00 ||||||This is not per day - 1 or 2 day stay is $300.00
58-2149128|1043270564|INPATIENT|WELL BABY (Day 3 and Beyond|$125.00 ||||||
58-2149128|1043270564|INPATIENT|PSYCH|$500.00 ||||||
58-2149128|1043270564|OUTPATIENT||||93451|$4|800.00 |||
58-2149128|1043270564|OUTPATIENT||||93452|$4|800.00 |||
58-2149128|1043270564|OUTPATIENT||||93454|$4|800.00 |||
58-2149128|1043270564|OUTPATIENT||||93455|$4|800.00 |||
58-2149128|1043270564|OUTPATIENT||||93456|$4|800.00 |||
58-2149128|1043270564|OUTPATIENT||||93457|$4|800.00 |||
58-2149128|1043270564|OUTPATIENT||||93458|$4|800.00 |||
58-2149128|1043270564|OUTPATIENT||||93459|$4|800.00 |||
58-2149128|1043270564|OUTPATIENT||||93460|$4|800.00 |||
58-2149128|1043270564|OUTPATIENT||||93461|$4|800.00 |||
58-2149128|1043270564|OUTPATIENT||||93462|$4|800.00 |||
58-2149128|1043270564|OUTPATIENT||||93453|$4|800.00 |||
58-2149128|1043270564|OUTPATIENT||||93530|$4|800.00 |||
58-2149128|1043270564|OUTPATIENT||||93531|$4|800.00 |||
58-2149128|1043270564|OUTPATIENT||||93532|$4|800.00 |||
58-2149128|1043270564|OUTPATIENT||||93533|$4|800.00 |||
58-2149128|1043270564|||||||||
58-2149128|1043270564|INPATIENT CARDIAC||||||216|218|218|$25|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||219|220|221|$21|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||222|$11|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||223|$11|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||224|$11|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||225|$11|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||226|$11|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||227|$11|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||228|229|230|$21|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||231|232|$21|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||233|234|$25|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||235|$21|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||236|$21|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||237|$13|00.00|ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||238|$13|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||242|243|244|$11|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||246|$11|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||247|$11|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||248|$11|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||249|$11|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||250|251|$11|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||258|$11|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||259|$11|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||260|261|262|$11|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||264|$10|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||265|$11|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||286|$10|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|INPATIENT CARDIAC||||||287|$10|000.00 |ICU Rates DO NOT apply when using Inpatient Cardiac DRG case rates
58-2149128|1043270564|||||||||
58-2149128|1043270564|INPATIENT|274|275-278||20%|||||Supplies/Implancts  dicounted at 20% of billed charges
58-2149128|1043270564|OUTPATIENT|274|275-278||20%|||||Supplies/Implancts  dicounted at 20% of billed charges
58-2149128|1043270564|PROFESSIONAL FEES|||20%|||||Professional Fees are always at a 20% disount regardless of case rate or per diems
58-2149128|1043270564|||||||||
58-2149128|1043270564|INPATIENT & OUTPATIENT||||||||Stoploss applies to both Inpatient and Outpatient - Threshold $35.000.00; % of Charges after Stoploss Threshold - 80%
58-2149128|1043270564|OUTPATIENT |||20%|||||Outpatient discount from billed charges  - 20%