1602 lines
71 KiB
XML
1602 lines
71 KiB
XML
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<?xml version="1.0" encoding="UTF-8"?>
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<Interchange>
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<ISA>
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<ISA01>00</ISA01>
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<ISA02 />
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<ISA03>00</ISA03>
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<ISA04 />
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<ISA05>ZZ</ISA05>
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<ISA06>993</ISA06>
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<ISA07>ZZ</ISA07>
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<ISA08>994</ISA08>
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<ISA09>180514</ISA09>
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<ISA10>1943</ISA10>
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<ISA11>^</ISA11>
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<ISA12>00501</ISA12>
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<ISA13>003042910</ISA13>
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<ISA14>0</ISA14>
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<ISA15>T</ISA15>
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<ISA16>{</ISA16>
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</ISA>
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<Division>
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<GS>
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<GS01>HB</GS01>
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<GS02>RITSA</GS02>
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<GS03>RBXMO</GS03>
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<GS04>20180514</GS04>
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<GS05>1943441</GS05>
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<GS06>3042910</GS06>
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<GS07>X</GS07>
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<GS08>005010X279A1</GS08>
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</GS>
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<Health_Care_Eligibility_Benefit_Response>
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<ST_0010>
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<ST01>271</ST01>
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<ST02>0001</ST02>
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<ST03>005010X279A1</ST03>
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</ST_0010>
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<BHT_0020>
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<BHT01>0022</BHT01>
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<BHT02>11</BHT02>
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<BHT03>123456701</BHT03>
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<BHT04>20180514</BHT04>
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<BHT05>1943438</BHT05>
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</BHT_0020>
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<Loop_HL_0030>
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<HL_0030>
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<HL01>1</HL01>
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<HL03>20</HL03>
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<HL04>1</HL04>
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</HL_0030>
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<Loop_NM1_0060>
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<NM1_0060>
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<NM101>PR</NM101>
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<NM102>2</NM102>
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<NM103>blue_cross_blue_shield_il</NM103>
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<NM108>PI</NM108>
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<NM109>621</NM109>
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</NM1_0060>
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</Loop_NM1_0060>
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<Loop_HL_0460>
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<HL_0460>
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<HL01>2</HL01>
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<HL02>1</HL02>
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<HL03>21</HL03>
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<HL04>1</HL04>
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</HL_0460>
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<Loop_NM1_0490>
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<NM1_0490>
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<NM101>2B</NM101>
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<NM102>2</NM102>
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<NM103>BCBS MOP</NM103>
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<NM108>SV</NM108>
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<NM109>1699849786XXXXXXXXX994X</NM109>
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</NM1_0490>
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</Loop_NM1_0490>
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<Loop_HL_0890>
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<HL_0890>
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<HL01>3</HL01>
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<HL02>2</HL02>
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<HL03>22</HL03>
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<HL04>0</HL04>
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</HL_0890>
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<TRN_0900>
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<TRN01>2</TRN01>
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<TRN02>123456701</TRN02>
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<TRN03>994BXMO</TRN03>
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</TRN_0900>
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<Loop_NM1_0920>
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<NM1_0920>
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<NM101>IL</NM101>
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<NM102>1</NM102>
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<NM103>WULKOWICZ</NM103>
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<NM104>JASON</NM104>
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<NM105>R</NM105>
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<NM108>MI</NM108>
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<NM109>QMF921053892</NM109>
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</NM1_0920>
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<REF_0930>
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<REF01>Q4</REF01>
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<REF02>BCB921053892</REF02>
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</REF_0930>
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<REF_0930>
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<REF01>6P</REF01>
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<REF02>IB1804</REF02>
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</REF_0930>
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<N3_0950>
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<N301>704 S EAST AVE</N301>
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</N3_0950>
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<N4_0960>
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<N401>OAK PARK</N401>
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<N402>IL</N402>
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<N403>60304</N403>
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</N4_0960>
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<DMG_1000>
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<DMG01>D8</DMG01>
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<DMG02>19640927</DMG02>
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<DMG03>M</DMG03>
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</DMG_1000>
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<INS_1010>
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<INS01>Y</INS01>
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<INS02>18</INS02>
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<INS03>001</INS03>
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<INS04>25</INS04>
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</INS_1010>
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<DTP_1030>
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<DTP01>291</DTP01>
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<DTP02>RD8</DTP02>
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<DTP03>20180101-99991231</DTP03>
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</DTP_1030>
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<DTP_1030>
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<DTP01>343</DTP01>
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<DTP02>D8</DTP02>
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<DTP03>20180131</DTP03>
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</DTP_1030>
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<Loop_EB_1050>
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<EB_1050>
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<EB01>1</EB01>
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<EB03>30</EB03>
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<EB05>Blue Choice Preferred</EB05>
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</EB_1050>
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</Loop_EB_1050>
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<Loop_EB_1050>
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<EB_1050>
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<EB01>D</EB01>
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<EB03>33</EB03>
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</EB_1050>
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<MSG_1180>
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<MSG01>THE FOLLOWING MUSCLE MANIPULATION MAXIMUM MAY BE COMBINED WITH OTHER THERAPY SERVICES.</MSG01>
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</MSG_1180>
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</Loop_EB_1050>
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<Loop_EB_1050>
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<EB_1050>
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<EB01>1</EB01>
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<EB03>1</EB03>
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<EB03>AL</EB03>
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<EB03>88</EB03>
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<EB03>MH</EB03>
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<EB12>W</EB12>
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</EB_1050>
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</Loop_EB_1050>
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<Loop_EB_1050>
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<EB_1050>
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<EB01>U</EB01>
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<EB03>47</EB03>
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<EB03>48</EB03>
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<EB11>U</EB11>
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<EB12>W</EB12>
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</EB_1050>
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<MSG_1180>
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<MSG01>INPATIENT FACILITY STAYS REQUIRE PREAUTHORIZATION</MSG01>
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</MSG_1180>
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<Loop_III_1190>
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<III_1190>
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<III01>ZZ</III01>
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<III02>21</III02>
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</III_1190>
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</Loop_III_1190>
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</Loop_EB_1050>
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<Loop_EB_1050>
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<EB_1050>
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||
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<EB01>U</EB01>
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<EB03>47</EB03>
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<EB03>48</EB03>
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||
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<EB11>U</EB11>
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<EB12>W</EB12>
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</EB_1050>
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<LS_1260>
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<LS01>2120</LS01>
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</LS_1260>
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<Loop_NM1_1270>
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<NM1_1270>
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<NM101>X3</NM101>
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<NM102>2</NM102>
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<NM103>CUSTOMER SERVICE</NM103>
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</NM1_1270>
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<PER_1310>
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<PER01>IC</PER01>
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<PER03>TE</PER03>
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<PER04>8009728088</PER04>
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</PER_1310>
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</Loop_NM1_1270>
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<LE_1330>
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<LE01>2120</LE01>
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</LE_1330>
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</Loop_EB_1050>
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<Loop_EB_1050>
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<EB_1050>
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<EB01>A</EB01>
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<EB02>IND</EB02>
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||
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<EB03>47</EB03>
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||
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<EB03>48</EB03>
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<EB06>23</EB06>
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||
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<EB08>.4</EB08>
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<EB11>U</EB11>
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<EB12>Y</EB12>
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</EB_1050>
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<MSG_1180>
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<MSG01>DAILY ROOM AND BOARD</MSG01>
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</MSG_1180>
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</Loop_EB_1050>
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<Loop_EB_1050>
|
||
|
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<EB_1050>
|
||
|
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<EB01>B</EB01>
|
||
|
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<EB02>IND</EB02>
|
||
|
|
<EB03>47</EB03>
|
||
|
|
<EB03>48</EB03>
|
||
|
|
<EB06>36</EB06>
|
||
|
|
<EB07>850</EB07>
|
||
|
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<EB11>U</EB11>
|
||
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<EB12>Y</EB12>
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||
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</EB_1050>
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<MSG_1180>
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<MSG01>DAILY ROOM AND BOARD</MSG01>
|
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</MSG_1180>
|
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<MSG_1180>
|
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<MSG01>EXCLUDED PROVIDER TYPES - 0Q,SF,0T,0D,0W,0O</MSG01>
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</MSG_1180>
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</Loop_EB_1050>
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<Loop_EB_1050>
|
||
|
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<EB_1050>
|
||
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<EB01>C</EB01>
|
||
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<EB02>IND</EB02>
|
||
|
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<EB03>30</EB03>
|
||
|
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<EB06>23</EB06>
|
||
|
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<EB07>2850</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
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<EB12>Y</EB12>
|
||
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</EB_1050>
|
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<MSG_1180>
|
||
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<MSG01>DAILY ROOM AND BOARD;EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL CARE - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;EMERGENCY ROOM SERVICES</MSG01>
|
||
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</MSG_1180>
|
||
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<MSG_1180>
|
||
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<MSG01>(NON-EMERGENCY) - INSTITUTIONAL;URGENT CARE INSTITUTIONAL;MUSCLE MANIPULATION - PROFESSIONAL;OFFICE VISIT - PROFESSIONAL;SPECIAL MEDICAL VISITS - INSTITUTIONAL</MSG01>
|
||
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</MSG_1180>
|
||
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</Loop_EB_1050>
|
||
|
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<Loop_EB_1050>
|
||
|
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<EB_1050>
|
||
|
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<EB01>C</EB01>
|
||
|
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<EB02>FAM</EB02>
|
||
|
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<EB03>30</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>8550</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>Y</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>DAILY ROOM AND BOARD;EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL CARE - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;EMERGENCY ROOM SERVICES</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>(NON-EMERGENCY) - INSTITUTIONAL;URGENT CARE INSTITUTIONAL;MUSCLE MANIPULATION - PROFESSIONAL;OFFICE VISIT - PROFESSIONAL;SPECIAL MEDICAL VISITS - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>G</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>30</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>13100</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>Y</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>DAILY ROOM AND BOARD;EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL CARE - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;EMERGENCY ROOM SERVICES</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>(NON-EMERGENCY) - INSTITUTIONAL;URGENT CARE INSTITUTIONAL;MUSCLE MANIPULATION - PROFESSIONAL;OFFICE VISIT - PROFESSIONAL;SPECIAL MEDICAL VISITS - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>G</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>30</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>6550</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>Y</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>DAILY ROOM AND BOARD;EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL CARE - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;EMERGENCY ROOM SERVICES</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>(NON-EMERGENCY) - INSTITUTIONAL;URGENT CARE INSTITUTIONAL;MUSCLE MANIPULATION - PROFESSIONAL;OFFICE VISIT - PROFESSIONAL;SPECIAL MEDICAL VISITS - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>J</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>47</EB03>
|
||
|
|
<EB03>48</EB03>
|
||
|
|
<EB06>36</EB06>
|
||
|
|
<EB07>0</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>Y</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>DAILY ROOM AND BOARD</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>PENALTY WILL BE THE LESSER OF 50% OF ALLOWED AMOUNT OR $1000</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>A</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>51</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB08>.4</EB08>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>W</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;URGENT CARE INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>A</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>UC</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB08>.4</EB08>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>W</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>A</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>52</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB08>.4</EB08>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>W</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY MEDICAL CARE - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>A</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>86</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB08>.4</EB08>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>Y</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>B</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>86</EB03>
|
||
|
|
<EB06>27</EB06>
|
||
|
|
<EB07>1000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>Y</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>A</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>33</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB08>.4</EB08>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>Y</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>MUSCLE MANIPULATION - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>F</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>33</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB09>P6</EB09>
|
||
|
|
<EB10>15</EB10>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>W</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>MUSCLE MANIPULATION - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>15 VISITS PER 1 YEAR CALENDAR BEGIN FOR ALL PLACES OF TRTMNT. THIS IS AN INDIVIDUAL BENEFIT MAXIMUM.</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>INCLUDED PROVIDER TYPES - BY,B0</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>F</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>33</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB09>P6</EB09>
|
||
|
|
<EB10>25</EB10>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>W</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>MUSCLE MANIPULATION - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>25 VISITS PER 1 YEAR CALENDAR BEGIN FOR ALL PLACES OF TRTMNT. THIS IS AN INDIVIDUAL BENEFIT MAXIMUM.</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EXCLUDED PROVIDER TYPES - BY,B0</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>A</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>98</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB08>.4</EB08>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>Y</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>OFFICE VISIT - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>F</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>98</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB09>P6</EB09>
|
||
|
|
<EB10>15</EB10>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>W</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>OFFICE VISIT - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>15 VISITS PER 1 YEAR CALENDAR BEGIN FOR ALL PLACES OF TRTMNT. THIS IS AN INDIVIDUAL BENEFIT MAXIMUM.</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>INCLUDED PROVIDER TYPES - BY,B0</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>A</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>BZ</EB03>
|
||
|
|
<EB06>27</EB06>
|
||
|
|
<EB08>0</EB08>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>Y</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>PHYSICAL HISTORY - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>F</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>BZ</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB09>P6</EB09>
|
||
|
|
<EB10>15</EB10>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>W</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>PHYSICAL HISTORY - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>15 VISITS PER 1 YEAR CALENDAR BEGIN FOR ALL PLACES OF TRTMNT. THIS IS AN INDIVIDUAL BENEFIT MAXIMUM.</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>INCLUDED PROVIDER TYPES - BY,B0</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>A</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>47</EB03>
|
||
|
|
<EB03>50</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB08>.4</EB08>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>Y</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>SPECIAL MEDICAL VISITS - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>A</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>47</EB03>
|
||
|
|
<EB03>48</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB08>.5</EB08>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>DAILY ROOM AND BOARD</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>50% COVERAGE PAYMENT LEVEL OF ALLOWED AMOUNT FOR ALL PLACES OF TRTMNT. APPLIES TO ALL CONDITIONS. PATIENT MAY BE RESP FOR AMT OVER THE ALLOWED AMT.</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EXCLUDED PROVIDER TYPES - 0Q,0T,0U,0V,0N</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>A</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>47</EB03>
|
||
|
|
<EB03>48</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB08>.5</EB08>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>DAILY ROOM AND BOARD</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>SPECIALIST - 50% COVERAGE PAYMENT LEVEL OF ALLOWED AMOUNT FOR ALL PLACES OF TRTMNT. EXCLUDED CONDITION(S) ALCOHOLISM DIAGNOSIS/DRUG ADDICTION DIAGNOSIS/MENTAL DIAGNOSIS/NON-SERIOUS MENTAL ILLNESS. /PERVASIVE DEVELOPMENTAL DISORDERS/SERIOUS MENTAL ILLNESS</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>INCLUDED PROVIDER TYPES - 0Q,0T,0U,0V,0N</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>B</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>47</EB03>
|
||
|
|
<EB03>48</EB03>
|
||
|
|
<EB06>36</EB06>
|
||
|
|
<EB07>1500</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>DAILY ROOM AND BOARD</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>47</EB03>
|
||
|
|
<EB03>48</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>15000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>DAILY ROOM AND BOARD</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>47</EB03>
|
||
|
|
<EB03>48</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>45000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>DAILY ROOM AND BOARD</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>J</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>47</EB03>
|
||
|
|
<EB03>48</EB03>
|
||
|
|
<EB06>36</EB06>
|
||
|
|
<EB07>500</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>DAILY ROOM AND BOARD</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>PER ADMISSION PENALTY WILL BE $500.</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>51</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>2850</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;URGENT CARE INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>51</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>8550</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;URGENT CARE INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>G</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>51</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>13100</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;URGENT CARE INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>G</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>51</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>6550</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;URGENT CARE INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>UC</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>2850</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>UC</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>8550</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>G</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>UC</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>13100</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>G</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>UC</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>6550</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>52</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>2850</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY MEDICAL CARE - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>52</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>8550</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY MEDICAL CARE - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>G</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>52</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>13100</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY MEDICAL CARE - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>G</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>52</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>6550</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY MEDICAL CARE - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>A</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>86</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB08>.5</EB08>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>50% COVERAGE PAYMENT LEVEL OF ALLOWED AMOUNT FOR ALL PLACES OF TRTMNT. APPLIES TO ALL CONDITIONS. PATIENT MAY BE RESP FOR AMT OVER THE ALLOWED AMT.</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EXCLUDED PROVIDER TYPES - 0Q,0T,0U,0V,0N</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>86</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>15000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>86</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>45000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>A</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>33</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB08>.5</EB08>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>MUSCLE MANIPULATION - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>50% COVERAGE PAYMENT LEVEL OF ALLOWED AMOUNT FOR ALL PLACES OF TRTMNT. APPLIES TO ALL CONDITIONS. PATIENT MAY BE RESP FOR AMT OVER THE ALLOWED AMT.</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EXCLUDED PROVIDER TYPES - 0Q,0T,0U,0V,0N</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>33</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>15000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>MUSCLE MANIPULATION - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>33</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>45000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>MUSCLE MANIPULATION - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>A</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>98</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB08>.5</EB08>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>OFFICE VISIT - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>50% COVERAGE PAYMENT LEVEL OF ALLOWED AMOUNT FOR ALL PLACES OF TRTMNT. APPLIES TO ALL CONDITIONS. PATIENT MAY BE RESP FOR AMT OVER THE ALLOWED AMT.</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EXCLUDED PROVIDER TYPES - 0Q,0T,0U,0V,0N</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>98</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>15000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>OFFICE VISIT - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>98</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>45000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>OFFICE VISIT - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>A</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>BZ</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB08>.5</EB08>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>PHYSICAL HISTORY - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>50% COVERAGE PAYMENT LEVEL OF ALLOWED AMOUNT FOR ALL PLACES OF TRTMNT. APPLIES TO ALL CONDITIONS. PATIENT MAY BE RESP FOR AMT OVER THE ALLOWED AMT.</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EXCLUDED PROVIDER TYPES - 0Q,0T,0U,0V,0N</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>BZ</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>15000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>PHYSICAL HISTORY - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>BZ</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>45000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>PHYSICAL HISTORY - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>A</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>47</EB03>
|
||
|
|
<EB03>50</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB08>.5</EB08>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>SPECIAL MEDICAL VISITS - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>50% COVERAGE PAYMENT LEVEL OF ALLOWED AMOUNT FOR ALL PLACES OF TRTMNT. APPLIES TO ALL CONDITIONS. PATIENT MAY BE RESP FOR AMT OVER THE ALLOWED AMT.</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EXCLUDED PROVIDER TYPES - 0Q,0T,0U,0V,0N</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>A</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>47</EB03>
|
||
|
|
<EB03>50</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB08>.5</EB08>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>SPECIAL MEDICAL VISITS - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>SPECIALIST - 50% COVERAGE PAYMENT LEVEL OF ALLOWED AMOUNT FOR ALL PLACES OF TRTMNT. EXCLUDED CONDITION(S) ALCOHOLISM DIAGNOSIS/DRUG ADDICTION DIAGNOSIS/MENTAL DIAGNOSIS/NON-SERIOUS MENTAL ILLNESS. /PERVASIVE DEVELOPMENTAL DISORDERS/SERIOUS MENTAL ILLNESS</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>INCLUDED PROVIDER TYPES - 0Q,0T,0U,0V,0N</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>47</EB03>
|
||
|
|
<EB03>50</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>15000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>SPECIAL MEDICAL VISITS - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>47</EB03>
|
||
|
|
<EB03>50</EB03>
|
||
|
|
<EB06>23</EB06>
|
||
|
|
<EB07>45000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>SPECIAL MEDICAL VISITS - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>D</EB01>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>BENEFIT ABBREVIATIONS - 0Q=MEDICARE APPROVED ECF,SF=SKILLED NURSING,0T=MEDICARE APPROVED HOME HEALTH SERVICE (COORDINATED HOME CARE),0D=COORDINATED HOME CARE,0W=JOINT COMMISSION ON ACCREDITATION OF HOSPITALS (JCAH) APPROVED EXTENDED CARE FACILITY (ECF),</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>0O=EXTENDED CARE/SKILLED NURSING FACILITY,BY=NAPRAPATH UNSOLICITEABLE,B0=NAPRAPATH UNSOLICITEABLE,0U=MEDICARE APPROVED FREESTANDING DIALYSIS CENTER,0V=ST LIC AMBUL SURGICTR,0N=NON-PLAN PROVIDER</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>30</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>2850</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>Y</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>DAILY ROOM AND BOARD;EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL CARE - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;EMERGENCY ROOM SERVICES</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>(NON-EMERGENCY) - INSTITUTIONAL;URGENT CARE INSTITUTIONAL;MUSCLE MANIPULATION - PROFESSIONAL;OFFICE VISIT - PROFESSIONAL;SPECIAL MEDICAL VISITS - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>30</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>8550</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>Y</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>DAILY ROOM AND BOARD;EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL CARE - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;EMERGENCY ROOM SERVICES</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>(NON-EMERGENCY) - INSTITUTIONAL;URGENT CARE INSTITUTIONAL;MUSCLE MANIPULATION - PROFESSIONAL;OFFICE VISIT - PROFESSIONAL;SPECIAL MEDICAL VISITS - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>G</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>30</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>13100</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>Y</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>DAILY ROOM AND BOARD;EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL CARE - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;EMERGENCY ROOM SERVICES</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>(NON-EMERGENCY) - INSTITUTIONAL;URGENT CARE INSTITUTIONAL;MUSCLE MANIPULATION - PROFESSIONAL;OFFICE VISIT - PROFESSIONAL;SPECIAL MEDICAL VISITS - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>G</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>30</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>6550</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>Y</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>DAILY ROOM AND BOARD;EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL CARE - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;EMERGENCY ROOM SERVICES</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>(NON-EMERGENCY) - INSTITUTIONAL;URGENT CARE INSTITUTIONAL;MUSCLE MANIPULATION - PROFESSIONAL;OFFICE VISIT - PROFESSIONAL;SPECIAL MEDICAL VISITS - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>F</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>33</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB09>P6</EB09>
|
||
|
|
<EB10>15</EB10>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>W</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>MUSCLE MANIPULATION - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>15 VISITS PER 1 YEAR CALENDAR BEGIN FOR ALL PLACES OF TRTMNT. THIS IS AN INDIVIDUAL BENEFIT MAXIMUM.</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>INCLUDED PROVIDER TYPES - BY,B0</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>F</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>33</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB09>P6</EB09>
|
||
|
|
<EB10>25</EB10>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>W</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>MUSCLE MANIPULATION - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>25 VISITS PER 1 YEAR CALENDAR BEGIN FOR ALL PLACES OF TRTMNT. THIS IS AN INDIVIDUAL BENEFIT MAXIMUM.</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EXCLUDED PROVIDER TYPES - BY,B0</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>F</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>98</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB09>P6</EB09>
|
||
|
|
<EB10>15</EB10>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>W</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>OFFICE VISIT - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>15 VISITS PER 1 YEAR CALENDAR BEGIN FOR ALL PLACES OF TRTMNT. THIS IS AN INDIVIDUAL BENEFIT MAXIMUM.</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>INCLUDED PROVIDER TYPES - BY,B0</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>F</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>BZ</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB09>P6</EB09>
|
||
|
|
<EB10>15</EB10>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>W</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>PHYSICAL HISTORY - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>15 VISITS PER 1 YEAR CALENDAR BEGIN FOR ALL PLACES OF TRTMNT. THIS IS AN INDIVIDUAL BENEFIT MAXIMUM.</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>INCLUDED PROVIDER TYPES - BY,B0</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>47</EB03>
|
||
|
|
<EB03>48</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>15000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>DAILY ROOM AND BOARD</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>47</EB03>
|
||
|
|
<EB03>48</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>45000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>DAILY ROOM AND BOARD</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>51</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>2850</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;URGENT CARE INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>51</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>8550</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;URGENT CARE INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>G</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>51</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>13100</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;URGENT CARE INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>G</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>51</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>6550</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ACCIDENT CARE - PROFESSIONAL;EMERGENCY ROOM INSTITUTIONAL;URGENT CARE INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>UC</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>2850</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>UC</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>8550</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>G</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>UC</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>13100</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>G</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>UC</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>6550</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ACCIDENT OFFICE VISIT - PROFESSIONAL;EMERGENCY MEDICAL OFFICE VISIT - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>52</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>2850</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY MEDICAL CARE - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>52</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>8550</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY MEDICAL CARE - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>G</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>52</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>13100</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY MEDICAL CARE - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>G</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>52</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>6550</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY MEDICAL CARE - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>86</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>15000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>86</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>45000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>EMERGENCY ROOM SERVICES (NON-EMERGENCY) - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>33</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>15000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>MUSCLE MANIPULATION - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>33</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>45000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>MUSCLE MANIPULATION - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>98</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>15000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>OFFICE VISIT - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>98</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>45000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>OFFICE VISIT - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>BZ</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>15000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>PHYSICAL HISTORY - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>BZ</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>45000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>PHYSICAL HISTORY - PROFESSIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>IND</EB02>
|
||
|
|
<EB03>47</EB03>
|
||
|
|
<EB03>50</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>15000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>SPECIAL MEDICAL VISITS - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>C</EB01>
|
||
|
|
<EB02>FAM</EB02>
|
||
|
|
<EB03>47</EB03>
|
||
|
|
<EB03>50</EB03>
|
||
|
|
<EB06>29</EB06>
|
||
|
|
<EB07>45000</EB07>
|
||
|
|
<EB11>U</EB11>
|
||
|
|
<EB12>N</EB12>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>SPECIAL MEDICAL VISITS - INSTITUTIONAL</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
<Loop_EB_1050>
|
||
|
|
<EB_1050>
|
||
|
|
<EB01>P</EB01>
|
||
|
|
</EB_1050>
|
||
|
|
<MSG_1180>
|
||
|
|
<MSG01>UNLESS OTHERWISE REQUIRED BY STATE LAW, THIS NOTICE IS NOT A GUARANTEE OF PAYMENT. BENEFITS ARE SUBJECT TO ALL CONTRACT LIMITS AND THE MEMBER'S STATUS ON THE DATE OF SERVICE. ACCUMULATED AMOUNTS SUCH AS DEDUCTIBLE MAY CHANGE AS ADDITIONAL CLAIMS ARE PROCESSED.</MSG01>
|
||
|
|
</MSG_1180>
|
||
|
|
</Loop_EB_1050>
|
||
|
|
</Loop_NM1_0920>
|
||
|
|
</Loop_HL_0890>
|
||
|
|
</Loop_HL_0460>
|
||
|
|
</Loop_HL_0030>
|
||
|
|
<SE_1790>
|
||
|
|
<SE01>250</SE01>
|
||
|
|
<SE02>0001</SE02>
|
||
|
|
</SE_1790>
|
||
|
|
</Health_Care_Eligibility_Benefit_Response>
|
||
|
|
<GE>
|
||
|
|
<GE01>1</GE01>
|
||
|
|
<GE02>3042910</GE02>
|
||
|
|
</GE>
|
||
|
|
</Division>
|
||
|
|
<IEA>
|
||
|
|
<IEA01>1</IEA01>
|
||
|
|
<IEA02>003042910</IEA02>
|
||
|
|
</IEA>
|
||
|
|
</Interchange>
|