INTERLINK Transplant & Specialty Network Listings

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Facility Name	Network	City	State	Service Type (INTERNAL)	Service Type	Age	Network Options	Performance Network	Case Rate	Inlier Days	Outpatient Transplant	Outlier Per Diem	Lesser of provision	Pre-/Post-Transplant Services	Harvesting Charges	Registry Search Fees	Organ Acquisition Charges	Implantable Devices	Stoploss/Threshold	Pre Transplant Phase	Transplant Phase	Post Transplant Phase	PPI: 1 Year Survival	Geocode Latitude	Geocode Longitude	Filename
AdventHealth Orlando	Transplant	Daytona Beach	FL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	$227,795	30	Provisions the same as Inpatient	$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			48% of Billed Charges	Begins at Evaluation	Begins on the Day of Mobilization or Preparative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		29.2103982	-81.1666499	1.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	$265,762	35	Provisions the same as Inpatient	$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			48% of Billed Charges	Begins at Evaluation	Begins on the Day of Mobilization or Preparative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		29.2103982	-81.1666499	1.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	$180,339	25	Provisions the same as Inpatient	$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			48% of Billed Charges	Begins at Evaluation	Begins on the Day of Mobilization or Preparative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		29.2103982	-81.1666499	1.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceSELECT	$294,237	40	Provisions the same as Inpatient	$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			48% of Billed Charges	Begins at Evaluation	Begins on the Day of Mobilization or Preparative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		29.2103982	-81.1666499	1.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Adult	Programs of Excellence	PerformanceSELECT	$337,897	45	Provisions the same as Inpatient	$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			48% of Billed Charges	Begins at Evaluation	Begins on the Day of Mobilization or Preparative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		29.2103982	-81.1666499	1.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$227,795	30		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			48% of Billed Charges	Begins at Evaluation	Begins on the Day of Mobilization or Preparative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.2103982	-81.1666499	1.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$265,762	35		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			48% of Billed Charges	Begins at Evaluation	Begins on the Day of Mobilization or Preparative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.2103982	-81.1666499	1.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$180,339	25		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			48% of Billed Charges	Begins at Evaluation	Begins on the Day of Mobilization or Preparative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.2103982	-81.1666499	1.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Pediatric	Programs of Excellence		$294,237	40		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			48% of Billed Charges	Begins at Evaluation	Begins on the Day of Mobilization or Preparative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.2103982	-81.1666499	1.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Pediatric	Programs of Excellence		$337,897	45		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			48% of Billed Charges	Begins at Evaluation	Begins on the Day of Mobilization or Preparative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.2103982	-81.1666499	1.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$364,474	25		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	48% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission for transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		29.2103982	-81.1666499	2.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Heart	Heart	Pediatric	Member's Choice		$364,474	25		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	48% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission for transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.2103982	-81.1666499	2.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Heart/Lung	Heart/Lung	Adult	Member's Choice		$455,592	25		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	48% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission for transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		29.2103982	-81.1666499	3.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Heart/Lung	Heart/Lung	Pediatric	Member's Choice		$455,592	25		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	48% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission for transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.2103982	-81.1666499	3.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$136,679	Cadaveric: 10 \| Living Donor: 8		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	48% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission for transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		29.2103982	-81.1666499	4.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Kidney	Kidney	Pediatric	Member's Choice		$136,679	Cadaveric: 10 \| Living Donor: 8		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	48% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission for transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.2103982	-81.1666499	4.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		$356,881	20		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	48% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission for transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		29.2103982	-81.1666499	5.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Kidney/Liver	Kidney/Liver	Pediatric	Member's Choice		$356,881	20		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	48% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission for transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.2103982	-81.1666499	5.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	$195,526	15		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	48% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission for transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		29.2103982	-81.1666499	6.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Kidney/Pancreas	Kidney/Pancreas	Pediatric	Member's Choice		$195,526	15		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	48% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission for transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.2103982	-81.1666499	6.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor: $271,456 \| Living Donor: $294,237	15		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	48% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission for transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		29.2103982	-81.1666499	7.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Liver	Liver	Pediatric	Programs of Excellence		Cadaveric Donor: $271,456 \| Living Donor: $294,237	15		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	48% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission for transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.2103982	-81.1666499	7.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Lung	Lung	Adult	Member's Choice		Single: $356,881 \| Bilateral: $455,592	20		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	48% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission for transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		29.2103982	-81.1666499	8.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Lung	Lung	Pediatric	Member's Choice		Single: $356,881 \| Bilateral: $455,592	20		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	48% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission for transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.2103982	-81.1666499	8.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Pancreas	Pancreas	Adult	Programs of Excellence		$125,360	10		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	48% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission for transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		29.2103982	-81.1666499	9.pdf
AdventHealth Orlando	Transplant	Daytona Beach	FL	Pancreas	Pancreas	Pediatric	Programs of Excellence		$125,360	10		$3,988 Med/Surg \| $4,367 ICU/CCU	70% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	48% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission for transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.2103982	-81.1666499	9.pdf
AdventHealth Porter	Transplant	Denver	CO	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor: $45,000 \| Living Donor: $51,000	16		$1,700 Med/Surg \| $2,250 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Invoice Cost	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends 365 Days from Discharge		43.0578056	-88.1078546	90.pdf
AdventHealth Porter	Transplant	Denver	CO	Liver	Liver	Adult	Member's Choice		$115,000	30		$1,700 Med/Surg \| $2,250 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Invoice Cost	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends 365 Days from Discharge		43.0578056	-88.1078546	91.pdf
Advocate Christ Medical Center	Transplant	Oak Lawn	IL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$198,000	30		$4,000 Med/Surg \| $5,000 ICU/CCU	75% of Billed Charges	65% of Billed Charges	Included in Case Rate	Included in Case Rate			If Charges Exceed $396,000, Then Payment will be the Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 180 Days After Discharge		41.7091132	-87.7770616	19.pdf
Advocate Christ Medical Center	Transplant	Oak Lawn	IL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$235,000	30		$4,000 Med/Surg \| $5,000 ICU/CCU	75% of Billed Charges	65% of Billed Charges	Included in Case Rate	Included in Case Rate			If Charges Exceed $470,000, Then Payment will be the Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 180 Days After Discharge		42.0386	-87.848	19.pdf
Advocate Christ Medical Center	Transplant	Oak Lawn	IL	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$120,000	12		$4,000 Med/Surg \| $5,000 ICU/CCU	75% of Billed Charges	65% of Billed Charges	Included in Case Rate	Included in Case Rate			If Charges Exceed $240,000, Then Payment will be the Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 180 Days After Discharge		42.0386	-87.848	19.pdf
Advocate Christ Medical Center	Transplant	Oak Lawn	IL	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Member's Choice		$194,000	15		$4,000 Med/Surg \| $5,000 ICU/CCU	75% of Billed Charges	65% of Billed Charges	Included in Case Rate	Included in Case Rate			If Charges Exceed $388,000, Then Payment will be the Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 180 Days After Discharge		42.0386	-87.848	19.pdf
Advocate Christ Medical Center	Transplant	Oak Lawn	IL	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$235,000	18		$4,000 Med/Surg \| $5,000 ICU/CCU	75% of Billed Charges	65% of Billed Charges			Included in Case Rate	50% of Billed Charges	If Charges Exceed $470,000, Then Payment will be the Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 180 Days After Discharge		41.7091132	-87.7770616	20.pdf
Advocate Christ Medical Center	Transplant	Oak Lawn	IL	Heart/Kidney	Heart/Kidney	Adult	Member's Choice		Cadaveric Donor: $282,500 \| Living Donor: $284,500	12		$4,000 Med/Surg \| $5,000 ICU/CCU	75% of Billed Charges	65% of Billed Charges			Included in Case Rate	50% of Billed Charges	If Charges Exceed $565,000 (Cadaveric) or $569,000 (Living), Then Payment will be the Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 180 Days After Discharge		41.7091132	-87.7770616	21.pdf
Advocate Christ Medical Center	Transplant	Oak Lawn	IL	Kidney	Kidney	Adult	Member's Choice		Cadaveric Donor: $95,000 \| Living Donor: $99,000	12		$4,000 Med/Surg \| $5,000 ICU/CCU	75% of Billed Charges	65% of Billed Charges			Included in Case Rate	50% of Billed Charges	If Charges Exceed $190,000 (Cadaveric) or 198,000 (Living), Then Payment will be the Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 180 Days After Discharge		41.7091132	-87.7770616	22.pdf
Ann & Robert H Lurie Children's Hospital of Chicago	Transplant	Chicago	IL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$140,000	30		$1,800 Med/Surg \| $2,400 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Charges for Autologous and Related Allogeneic transplants included in the Transplant Case Rate. Unrelated stem cell sources are payable at invoice cost.	Charges for Autologous and Related Allogeneic transplants included in the Transplant Case Rate. Unrelated stem cell sources are payable at invoice cost.			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year post-transplant		41.8339037	-87.8720468	23.pdf
Ann & Robert H Lurie Children's Hospital of Chicago	Transplant	Chicago	IL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$160,000	40		$1,800 Med/Surg \| $2,400 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Charges for Autologous and Related Allogeneic transplants included in the Transplant Case Rate. Unrelated stem cell sources are payable at invoice cost.	Charges for Autologous and Related Allogeneic transplants included in the Transplant Case Rate. Unrelated stem cell sources are payable at invoice cost.			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year post-transplant		41.8339037	-87.8720468	23.pdf
Ann & Robert H Lurie Children's Hospital of Chicago	Transplant	Chicago	IL	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$110,000	30		$1,800 Med/Surg \| $2,400 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Charges for Autologous and Related Allogeneic transplants included in the Transplant Case Rate. Unrelated stem cell sources are payable at invoice cost.	Charges for Autologous and Related Allogeneic transplants included in the Transplant Case Rate. Unrelated stem cell sources are payable at invoice cost.			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year post-transplant		41.8339037	-87.8720468	23.pdf
Ann & Robert H Lurie Children's Hospital of Chicago	Transplant	Chicago	IL	Blood/Marrow (Tandem)	Tandem Auto to Allo	Pediatric	Programs of Excellence		65% of Billed Charges	30 Days from Last Stem Cell Infusion		$1,800 Med/Surg \| $2,400 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Charges for Autologous and Related Allogeneic transplants included in the Transplant Case Rate. Unrelated stem cell sources are payable at invoice cost.	Charges for Autologous and Related Allogeneic transplants included in the Transplant Case Rate. Unrelated stem cell sources are payable at invoice cost.			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year post-transplant		41.8339037	-87.8720468	23.pdf
Ann & Robert H Lurie Children's Hospital of Chicago	Transplant	Chicago	IL	Blood/Marrow (Tandem)	Tandem Auto to Auto	Pediatric	Programs of Excellence		65% of Billed Charges	30 Days from Last Stem Cell Infusion		$1,800 Med/Surg \| $2,400 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Charges for Autologous and Related Allogeneic transplants included in the Transplant Case Rate. Unrelated stem cell sources are payable at invoice cost.	Charges for Autologous and Related Allogeneic transplants included in the Transplant Case Rate. Unrelated stem cell sources are payable at invoice cost.			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year post-transplant		41.8339037	-87.8720468	23.pdf
Ann & Robert H Lurie Children's Hospital of Chicago	Transplant	Chicago	IL	Heart	Heart	Pediatric	Programs of Excellence		$125,000	25		$1,800 Med/Surg \| $2,400 ICU/CCU	90% of Billed Charges	75% of Billed Charges	N/A	N/A	Included in Case Rate	Invoice Cost	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days have Expired	Ends One (1) Year post-transplant		41.8339037	-87.8720468	24.pdf
Ann & Robert H Lurie Children's Hospital of Chicago	Transplant	Chicago	IL	Intestine	Intestine	Pediatric	Member's Choice		65% of Billed Charges	6 Months		N/A	N/A	75% of Billed Charges			Included in Case Rate		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days have Expired	Ends One (1) Year post-transplant		41.8339037	-87.8720468	25.pdf
Ann & Robert H Lurie Children's Hospital of Chicago	Transplant	Chicago	IL	Kidney	Kidney	Pediatric	Programs of Excellence		$65,000	15		$1,800 Med/Surg \| $2,400 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate		50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year post-transplant		41.8339037	-87.8720468	26.pdf
Ann & Robert H Lurie Children's Hospital of Chicago	Transplant	Chicago	IL	Liver	Liver	Pediatric	Programs of Excellence		$155,000	25		$1,800 Med/Surg \| $2,400 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate		50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year post-transplant		41.8339037	-87.8720468	27.pdf
Arthur G. James Cancer Hospital	Transplant	Columbus	OH	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	$230,946	N/A		N/A	75% of Billed Charges	60% of Billed Charges	Included in Case Rate	Invoice Cost			If Billed Charges Exceed $546,978, Payment will be the Transplant Case Rate, Plus 55% of the Excess Charges	Begins at Evaluation	Begins on the Earlier of Transplant Admission, Preparatory Therapy, or Transplant Event and Ends at Discharge	Ends 365 Days from Discharge		39.9828667	-83.1312539	28.pdf
Arthur G. James Cancer Hospital	Transplant	Columbus	OH	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	Unrelated: $273,489 \| Matched Unrelated: $255,256 \| Mini: 70% of Billed Charges	N/A		N/A	75% of Billed Charges	60% of Billed Charges	Included in Case Rate	Invoice Cost			If Billed Charges Exceed \| Unrelated: $698,915, Matched Unrelated: $680,683 \| Payment will be the Transplant Case Rate, Plus 55% of the Excess Charges	Begins at Evaluation	Begins on the Earlier of Transplant Admission, Preparatory Therapy, or Transplant Event and Ends at Discharge	Ends 365 Days from Discharge		39.9828667	-83.1312539	28.pdf
Arthur G. James Cancer Hospital	Transplant	Columbus	OH	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	$145,861 \| Outpatient: $91,132 \| Mini BMT: 70% of Billed Charges	N/A		N/A	75% of Billed Charges	60% of Billed Charges	Included in Case Rate	Invoice Cost			If Billed Charges Exceed $395,038 or $246,81 for Outpatient, Payment will be the Transplant Case Rate, Plus 55% of the Excess Charges	Begins at Evaluation	Begins on the Earlier of Transplant Admission, Preparatory Therapy, or Transplant Event and Ends at Discharge	Ends 365 Days from Discharge		39.9828667	-83.1312539	28.pdf
Aurora St Luke's Medical Center	Transplant	Milwaukee	WI	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$120,000	12		$4,000 Med/Surg \| $5,000 ICU/CCU	75% of Billed Charges	65% of Billed Charges	Included in Case Rate	Included in Case Rate			$240,000 \| 65% of Billed Charges Beyond Threshold Amount	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and applicable Outlier Days have expired	Ends 180 Days from Inlier and applicable Outlier Days		43.0578056	-88.1078546	29.pdf
Aurora St Luke's Medical Center	Transplant	Milwaukee	WI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$200,000	20		$4,000 Med/Surg \| $5,000 ICU/CCU	75% of Billed Charges	65% of Billed Charges	Included in Case Rate				$400,000 \| 65% of Billed Charges Beyond Threshold Amount	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and applicable Outlier Days have expired	Ends 180 Days from Inlier and applicable Outlier Days		43.0578056	-88.1078546	29.pdf
Aurora St Luke's Medical Center	Transplant	Milwaukee	WI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$275,000	25		$4,000 Med/Surg \| $5,000 ICU/CCU	75% of Billed Charges	65% of Billed Charges	Included in Case Rate	Included in Case Rate			$550,000 \| 65% of Billed Charges Beyond Threshold Amount	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and applicable Outlier Days have expired	Ends 180 Days from Inlier and applicable Outlier Days		43.0578056	-88.1078546	29.pdf
Aurora St Luke's Medical Center	Transplant	Milwaukee	WI	Blood/Marrow (Tandem)	Tandem Auto to Auto	Adult	Member's Choice		$194,000	15		$4,000 Med/Surg \| $5,000 ICU/CCU	75% of Billed Charges	65% of Billed Charges	Included in Case Rate				If Billed Charges Exceed $388,000, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and applicable Outlier Days have expired	Ends 180 Days from Inlier and applicable Outlier Days		43.0578056	-88.1078546	29.pdf
Aurora St Luke's Medical Center	Transplant	Milwaukee	WI	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor: $95,000 \| Living Donor: $99,000	12		$4,000 Med/Surg \| $5,000 ICU/CCU	75% of Billed Charges	65% of Billed Charges			Included in Case Rate	Reimbursed at 50% of Hospitals Billed Charges	Cadaveric Donor: $190,000 \| Living Donor: $198,000 \| 65% of Billed Charges Beyond the Threshold Amounts	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 180 Days from Discharge		43.0578056	-88.1078546	30.pdf
Aurora St Luke's Medical Center	Transplant	Milwaukee	WI	Liver	Liver	Adult	Member's Choice		Cadaveric Donor: $220,000 \| Living Donor: $230,000	17		$4,000 Med/Surg \| $5,000 ICU/CCU	75% of Billed Charges	65% of Billed Charges			Included in Case Rate	Reimbursed at 50% of Hospitals Billed Charges	Cadaveric Donor: $440,000 \| Living Donor: $460,000 \| 65% of Billed Charges Beyond the Threshold Amounts	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 180 Days from Discharge		43.0578056	-88.1078546	31.pdf
Aurora St Luke's Medical Center	Transplant	Milwaukee	WI	Dual Organ	Multi-Organ	Adult	Member's Choice		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	Equal to Number of Days of more Expensive Organ		$4,000 Med/Surg \| $5,000 ICU/CCU	75% of Billed Charges	65% of Billed Charges			Included in Case Rate	Reimbursed at 50% of Hospitals Billed Charges	100% of Higher Cost Organ Threshold, Plus 50% of Lower Cost Organ Threshold	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 180 Days from Discharge		43.0578056	-88.1078546	32.pdf
Aurora St Luke's Medical Center	Transplant	Milwaukee	WI	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$235,000	18		$4,000 Med/Surg \| $5,000 ICU/CCU	N/A	65% of Billed Charges			Included in Case Rate	Reimbursed at 50% of Hospitals Billed Charges	$470,000 \| 65% of Billed Charges Beyond Threshold Amount	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 180 Days from Discharge		43.0578056	-88.1078546	33.pdf
Avera McKennan Hospital	Transplant	Sioux Falls	SD	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$95,000	30		$2,600	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	34.pdf
Avera McKennan Hospital	Transplant	Sioux Falls	SD	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$133,000	35		$2,600	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	34.pdf
Avera McKennan Hospital	Transplant	Sioux Falls	SD	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$145,000	40		$2,600	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	34.pdf
Avera McKennan Hospital	Transplant	Sioux Falls	SD	Kidney	Kidney	Adult	Member's Choice		$80,000	8		$2,600	80% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	35.pdf
Avera McKennan Hospital	Transplant	Sioux Falls	SD	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$120,000	10		$2,600	80% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	36.pdf
Avera McKennan Hospital	Transplant	Sioux Falls	SD	Pancreas	Pancreas	Adult	Member's Choice		$90,000	10		$2,600	80% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	37.pdf
Barnes-Jewish Hospital	Transplant	St Louis	MO	Heart/Lung	Heart/Lung	Adult	Member's Choice		70% of Billed Charges	N/A		N/A	N/A	70% of Billed Charges			Included in Case Rate	Reimbursed at 70% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant admission and Ends at the Earlier of Discharge or Transfer to Inpatient Rehabilitation Unit or Facility	Ends One (1) Year from Discharge		43.0578056	-88.1078546	38.pdf
Barnes-Jewish Hospital	Transplant	St Louis	MO	Pancreas	Pancreas	Adult	Programs of Excellence		Hospital: 70% of Billed Charges \| Professional: 70% of Billed Charges	N/A		N/A	N/A	70% of Billed Charges			Included in Case Rate	Reimbursed at 70% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant admission and Ends at the Earlier of Discharge or Transfer to Inpatient Rehabilitation Unit or Facility	Ends One (1) Year from Discharge		43.0578056	-88.1078546	39.pdf
Barnes-Jewish Hospital	Transplant	St Louis	MO	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $213,983 \| Professional: $37,409	N/A		N/A	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at the Earlier of Discharge or Transfer to Inpatient rehabilitation	Ends One (1) Year from Discharge		43.0578056	-88.1078546	40.pdf
Barnes-Jewish Hospital	Transplant	St Louis	MO	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $282,572 \| Professional: $49,393	N/A		N/A	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at the Earlier of Discharge or Transfer to Inpatient rehabilitation	Ends One (1) Year from Discharge		43.0578056	-88.1078546	40.pdf
Barnes-Jewish Hospital	Transplant	St Louis	MO	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $146,110 \| Professional: $25,543	N/A		N/A	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	N/A			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at the Earlier of Discharge or Transfer to Inpatient rehabilitation	Ends One (1) Year from Discharge		43.0578056	-88.1078546	40.pdf
Barnes-Jewish Hospital	Transplant	St Louis	MO	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $280,556 \| Professional: $63,832	N/A		N/A	80% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 70% of Billed Charges	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant admission and Ends at the Earlier of Discharge or Transfer to Inpatient Rehabilitation Unit or Facility	Ends One (1) Year from Discharge		43.0578056	-88.1078546	41.pdf
Barnes-Jewish Hospital	Transplant	St Louis	MO	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor Hospital: $116,481 \| Cadaveric Donor Professional: $23,040 \| Living Donor Hospital: $126,065 \| Living Donor Professional: $33,159	N/A		N/A	80% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 70% of Billed Charges	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant admission and Ends at the Earlier of Discharge or Transfer to Inpatient Rehabilitation Unit or Facility	Ends One (1) Year from Discharge		43.0578056	-88.1078546	42.pdf
Barnes-Jewish Hospital	Transplant	St Louis	MO	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	70% of Billed Charges	N/A		N/A	N/A	70% of Billed Charges			Included in Case Rate	Reimbursed at 70% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant admission and Ends at the Earlier of Discharge or Transfer to Inpatient Rehabilitation Unit or Facility	Ends One (1) Year from Discharge		43.0578056	-88.1078546	43.pdf
Barnes-Jewish Hospital	Transplant	St Louis	MO	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor Hospital: $230,117 \| Cadaveric Donor Professional: $55,784 \| Living Donor Hospital: $262,030 \| Living Donor Professional: $56,213	N/A		N/A	80% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 70% of Billed Charges	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant admission and Ends at the Earlier of Discharge or Transfer to Inpatient Rehabilitation Unit or Facility	Ends One (1) Year from Discharge		43.0578056	-88.1078546	44.pdf
Barnes-Jewish Hospital	Transplant	St Louis	MO	Blood/Marrow (Tandem)	Tandem Auto to Allo	Adult	Member's Choice		1st Transplant: Hospital $146,110 Professional $25,543 \| 2nd Transplant: Hospital $133,793 Professional $23,374	N/A		N/A	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at the Earlier of Discharge or Transfer to Inpatient rehabilitation	Ends One (1) Year from Discharge		43.0578056	-88.1078546	45.pdf
Barnes-Jewish Hospital	Transplant	St Louis	MO	Multi-Organ	Multi-Organ	Adult	Member's Choice		Hospital: 70% of Billed Charges \| Professional: 70% of Billed Charges	N/A		N/A	N/A	70% of Billed Charges			Included in Case Rate	Reimbursed at 70% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant admission and Ends at the Earlier of Discharge or Transfer to Inpatient Rehabilitation Unit or Facility	Ends One (1) Year from Discharge		43.0578056	-88.1078546	46.pdf
Barnes-Jewish Hospital	Transplant	St Louis	MO	Lung	Lung	Adult	Programs of Excellence	PerformanceELITE	Single Lung Hospital: $235,669 \| Single Lung Professional: $56,028 \| Bilateral Lung Hospital: $289,448 \| Bilateral Lung Professional: $62,849	N/A		N/A	80% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 70% of Billed Charges	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant admission and Ends at the Earlier of Discharge or Transfer to Inpatient Rehabilitation Unit or Facility	Ends One (1) Year from Discharge		43.0578056	-88.1078546	47.pdf
Baylor Scott & White Temple	Transplant	Temple	TX	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$170,846	N/A		N/A	90% of Billed Charges	70% of Billed Charges	Included in Case Rate	N/A			If Billed Charges Exceed $341,693, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the First Day of Ablative Therapy and Ends on the Day of Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	48.pdf
Baylor Scott & White Temple	Transplant	Temple	TX	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$130,000	N/A		N/A	90% of Billed Charges	70% of Billed Charges			Included in the Case Rate	Reimbursed at 65% of Billed Charges	If Billed Charges Exceed $260,000, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	49.pdf
Baylor Scott & White Temple	Transplant	Temple	TX	Pancreas	Pancreas	Adult	Programs of Excellence		$151,864	N/A		N/A	90% of Billed Charges	70% of Billed Charges			Included in the Case Rate	Reimbursed at 65% of Billed Charges	If Billed Charges Exceed $303,728, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	50.pdf
Baylor Scott & White Temple	Transplant	Temple	TX	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$132,881	N/A		N/A	90% of Billed Charges	70% of Billed Charges			Included in the Case Rate	Reimbursed at 65% of Billed Charges	If Billed Charges Exceed $265,762, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	51.pdf
Baylor Scott & White Temple	Transplant	Temple	TX	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$189,830	N/A		N/A	90% of Billed Charges	70% of Billed Charges			Included in the Case Rate	Reimbursed at 65% of Billed Charges	If Billed Charges Exceed $379,660, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	52.pdf
Baylor Scott and White All Saints Medical Center - Fort Worth	Transplant	Fort Worth	TX	Kidney	Kidney	Adult	Member's Choice		Living Donor Hospital: $34,500 \| Living Donor Professional: $28,000 \| Cadaveric Donor Hospital: $42,500 \| Cadaveric Donor Professional: $16,000	Living Donor: 5 \| Cadaveric Donor: 7		Hospital: $2,500 \| Professional: $600	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	53.pdf
Baylor Scott and White All Saints Medical Center - Fort Worth	Transplant	Fort Worth	TX	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		Hospital: $109,500 \| Professional: $46,500	15		Hospital: $2,500 \| Professional: $600	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	59.pdf
Baylor Scott and White All Saints Medical Center - Fort Worth	Transplant	Fort Worth	TX	Liver	Liver	Adult	Member's Choice		Hospital: $109,500 \| Professional: $46,500	15		Hospital: $2,500 \| Professional: $600	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	54.pdf
Baylor University Medical Center	Transplant	Dallas	TX	Islet	Islet	Adult	Member's Choice		75% of Billed Charges	N/A		N/A	N/A	75% of Billed Charges	75% of Billed Charges				N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	55.pdf
Baylor University Medical Center	Transplant	Dallas	TX	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $51,500 \| Professional: $23,460	12	80% of Billed Charges	Hospital: $2,500 \| Professional: $600	80% of Billed Charges	75% of Billed Charges	Included in Case Rate	N/A			70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	56.pdf
Baylor University Medical Center	Transplant	Dallas	TX	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $97,500 \| Professional: $29,325	18	80% of Billed Charges	Hospital: $2,500 \| Professional: $600	80% of Billed Charges	75% of Billed Charges	Included in Case Rate	N/A			70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	56.pdf
Baylor University Medical Center	Transplant	Dallas	TX	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $119,500 \| Professional: $34,500	20	80% of Billed Charges	Hospital: $2,500 \| Professional: $600	80% of Billed Charges	75% of Billed Charges	Included in Case Rate	Reimbursed at 75% of Billed Charges			70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	56.pdf
Baylor University Medical Center	Transplant	Dallas	TX	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $115,000 \| Professional: $35,000	15		Hospital: $2,500 \| Professional: $600	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 75% of Billed Charges	70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	57.pdf
Baylor University Medical Center	Transplant	Dallas	TX	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Living Donor Hospital: $34,500 \| Living Donor Professional: $28,000 \| Cadaveric Donor Hospital: $42,500 \| Cadaveric Donor Professional: $16,000	Living Donor: 5 \| Cadaveric Donor: 7		Hospital: $2,500 \| Professional: $600	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	58.pdf
Baylor University Medical Center	Transplant	Dallas	TX	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $67,500 \| Professional: $23,000	7		Hospital: $2,500 \| Professional: $600	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	59.pdf
Baylor University Medical Center	Transplant	Dallas	TX	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $109,500 \| Professional: $46,500	15		Hospital: $2,500 \| Professional: $600	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	60.pdf
Baylor University Medical Center	Transplant	Dallas	TX	Lung	Lung	Adult	Member's Choice		Single Lung Hospital: $111,500 \| Single Lung Professional: $31,500 \| Bilateral Lung Hospital: $122,500 \| Bilateral Lung Professional: $33,500	Single Lung: 14 \| Bilateral Lung: 18		Hospital $2,500 \| Professional $600	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	61.pdf
Baylor University Medical Center	Cellular Immunotherapy	Dallas	TX	Cellular Immunotherapy	Cellular Immunotherapy				Hospital: 60% of Billed Charges \| Professional: 70% of Billed Charges \| Drug Cost: 100% of Invoice Cost	N/A		N/A	N/A	Hospital: 60% of Billed Charges \| Professional: 70% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends 365 Days from Discharge		43.0578056	-88.1078546	62.pdf
Baystate Medical Center	Transplant	Springfield	MA	Kidney	Kidney	Adult	Member's Choice		Cadaveric Donor: $38,360 \| Living Donor: $89,600	10		Cadaveric: $3,640 Med/Surg; $4,480 ICU/CCU \| Living: $2,968 Med/Surg; $4,480 ICU/CCU	85% of Billed Charges	67.47% of Billed Charges			Cadaveric: 100% of Invoice Cost \| Living: Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	63.pdf
Beth Israel Deaconess Medical Center	Transplant	Boston	MA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		Hospital: $127,196 \| Professional: $15,804	40		80% of Billed Charges	85% of Billed Charges	65% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	64.pdf
Beth Israel Deaconess Medical Center	Transplant	Boston	MA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		Hospital: $160,092 \| Professional $15,908	42		80% of Billed Charges	85% of Billed Charges	65% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	64.pdf
Beth Israel Deaconess Medical Center	Transplant	Boston	MA	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		Hospital: $86,196 \| Professional: $12,804	30		80% of Billed Charges	85% of Billed Charges	65% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	64.pdf
Beth Israel Deaconess Medical Center	Transplant	Boston	MA	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $156,140 \| Professional: $18,860	18		80% of Billed Charges	85% of Billed Charges	65% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	65.pdf
Beth Israel Deaconess Medical Center	Transplant	Boston	MA	Pancreas	Pancreas	Adult	Programs of Excellence		Hospital: $108,820 \| Professional: $10,180	15		80% of Billed Charges	85% of Billed Charges	65% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	66.pdf
Beth Israel Deaconess Medical Center	Transplant	Boston	MA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	Hospital (Cadaveric Donor): $69,235 \| Physicians (Cadaveric Donor): $5,765 \| Hospital (Living Donor): $60,958 \| Physicians (Living Donor): $12,042	12		80% of Billed Charges	85% of Billed Charges	65% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	67.pdf
Beth Israel Deaconess Medical Center	Transplant	Boston	MA	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	Hospital (Cadaveric Donor): $151,511 \| Physicians (Cadaveric Donor): $17,489 \| Hospital (Living Donor): $142,589 \| Physicians (Living Donor): $42,411	21		80% of Billed Charges	85% of Billed Charges	65% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	68.pdf
Beth Israel Deaconess Medical Center	Transplant	Boston	MA	Multi-Organ	Multi-Organ	Adult	Member's Choice		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	21		80% of Billed Charges	85% of Billed Charges	65% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	69.pdf
Boston Children's Hospital	Transplant	Boston	MA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		Hospital: $185,000 \| Professional: 85% of Billed Charges	40		Hospital: $4,000 \| Professional: 85% of Billed Charges	95% of Billed Charges	85% of Billed Charges	Included in Case Rate	100% of Invoice Cost			80% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	70.pdf
Boston Children's Hospital	Transplant	Boston	MA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		Hospital: $195,000 \| Professional: 85% of Billed Charges	40		Hospital: $4,000 \| Professional: 85% of Billed Charges	95% of Billed Charges	85% of Billed Charges	Included in Case Rate	100% of Invoice Cost			80% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	70.pdf
Boston Children's Hospital	Transplant	Boston	MA	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		Hospital: $160,000 \| Professional: 85% of Billed Charges	40		Hospital: $4,000 \| Professional: 85% of Billed Charges	95% of Billed Charges	85% of Billed Charges	Included in Case Rate	100% of Invoice Cost			80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	70.pdf
Boston Children's Hospital	Transplant	Boston	MA	Heart	Heart	Pediatric	Programs of Excellence		Hospital: $175,000 \| Professional: 85% of Billed Charges	30		Hospital: $4,000 \| Professional: 85% of Billed Charges	95% of Billed Charges	85% of Billed Charges			Included in Case Rate	N/A	80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	71.pdf
Boston Children's Hospital	Transplant	Boston	MA	Kidney	Kidney	Pediatric	Programs of Excellence		Hospital: $80,000 \| Professional: 85% of Billed Charges	12		Hospital: $4,000 \| Professional: 85% of Billed Charges	95% of Billed Charges	85% of Billed Charges			Included in Case Rate	N/A	80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	72.pdf
Boston Children's Hospital	Transplant	Boston	MA	Liver	Liver	Pediatric	Programs of Excellence		Hospital: $180,000 \| Professional: 85% of Billed Charges	35		Hospital: $4,000 \| Professional: 85% of Billed Charges	95% of Billed Charges	85% of Billed Charges			Included in Case Rate	N/A	80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	73.pdf
Boston Children's Hospital	Transplant	Boston	MA	Lung	Lung	Pediatric	Programs of Excellence		Hospital: $180,000 \| Professional: 85% of Billed Charges	25		Hospital: $4,000 \| Professional: 85% of Billed Charges	95% of Billed Charges	85% of Billed Charges			Included in Case Rate	N/A	80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	74.pdf
Boston Children's Hospital	Congenital Heart Defect	Boston	MA	Congenital Heart Defect	Congenital Heart Defect				Hospital: Surgical Event & Inpatient (Med/Surg/NICU/PICU) = 80% of Billed Charges \| Professional: Surgical Event & Inpatient (Med/Surg/NICU/PICU) = 85% of Billed Charges	N/A		N/A	N/A	Hospital: 80% of Billed Charges \| Professional: 85% of Billed Charges				During Inpatient Stay: 80% of Billed Charges \| Otherwise: 85% of Billed Charges	N/A	Begins on the Date of Referral to INTERLINK	Begins Upon Referral to INTERLINK &/Or when Patient is Admitted to Facility	Coverage Remains Active Until Patient No Longer Requires Pediatric Heart Services		43.0578056	-88.1078546	75.pdf
Brigham and Women's Hospital	Transplant	Boston	MA	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $150,000 \| Professional: 80% of Billed Charges	20		N/A	N/A	80% of Billed Charges			Included in Case Rate	N/A	65% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	76.pdf
Brigham and Women's Hospital	Transplant	Boston	MA	Kidney	Kidney	Adult	Member's Choice		Hospital Cadaveric Donor: $67,800 \| Hospital Living Donor: $62,500 \| Professional: 80% of Billed Charges	Living: 15 \| Cadaveric: 12		$2,260 Med/Surg \| $2,920 ICU/CCU	90% of Billed Charges for hospital	80% of Billed Charges			Included in Case Rate	N/A	65% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	77.pdf
Brigham and Women's Hospital	Transplant	Boston	MA	Lung	Lung	Adult	Member's Choice		Hospital (Single Lung): $140,000 \| Hospital (Bilateral Lung): $175,000 \| Physicians: 80% of Billed Charges	25		$2,260 Med/Surg \| $2,920 ICU/CCU	90% of Billed Charges for hospital	80% of Billed Charges			Included in Case Rate	N/A	65% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	78.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceELITE	$120,000	25	N/A	$3,200 Med/Surg \| $4,000 ICU/CCU	80% of Billed Charges	60% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from the end of Inlier Days and applicable Outlier Days		34.053691	-118.242766	79.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceELITE	$140,000	30	N/A	$3,200 Med/Surg \| $4,000 ICU/CCU	80% of Billed Charges	60% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from the end of Inlier Days and applicable Outlier Days		34.053691	-118.242766	79.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceELITE	$160,000	35	N/A	$3,200 Med/Surg \| $4,000 ICU/CCU	80% of Billed Charges	60% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from the end of Inlier Days and applicable Outlier Days		34.053691	-118.242766	79.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$143,000	16		$2,400. Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	60% of Billed Charges			Included in Case Rate	Charges Included in Case Rate	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends upon Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	80.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Heart/Lung	Heart/Lung	Adult	Member's Choice		$192,000	29		$2,400 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	60% of Billed Charges			Included in Case Rate	Charges Included in Case Rate	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends upon Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	81.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Kidney	Kidney	Adult	Member's Choice		$103,000	8		$2,400 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	60% of Billed Charges			Included in Case Rate	Charges Included in Case Rate	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends upon Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	82.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Kidney	Kidney	Pediatric	Member's Choice		$103,000	8		$2,400 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	60% of Billed Charges			Included in Case Rate	Charges Included in Case Rate	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends upon Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	83.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$130,000	13		$2,400 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	60% of Billed Charges			Included in Case Rate	Charges Included in Case Rate	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends upon Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	84.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	$182,000	24		$2,400 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	60% of Billed Charges			Included in Case Rate	Charges Included in Case Rate	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends upon Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	85.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Lung	Lung	Adult	Programs of Excellence	PerformanceELITE	$160,000	24		$2,400 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	60% of Billed Charges			Included in Case Rate	Charges Included in Case Rate	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends upon Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	86.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Pancreas	Pancreas	Adult	Member's Choice		$107,000	10		$2,400 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	60% of Billed Charges			Included in Case Rate	Charges Included in Case Rate	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends upon Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	87.pdf
Cedars-Sinai Medical Center	Destination VAD	Los Angeles	CA	Destination VAD	Destination VAD				Surgical Event Hospital: 55% of Billed Charges \| Surgical Event Professional: 60% of Billed Charges	N/A		Inpatient Care: Hospital 55% of Billed Charges \| Professional 60% of Billed Charges	N/A	Outpatient Care: Hospital 55% of Billed Charges; Professional 60% of Billed Charges				55% of Billed Charges	N/A	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		34.053691	-118.242766	88.pdf
Cedars-Sinai Medical Center	Bariatric	Los Angeles	CA	Bariatric	Bariatric				Duodenal Switch: $28,000 \| Gastric Banding: $23,000 \| Gastric Bypass: $26,000 \| Gastric Sleeve: $16,000 \| All Professional Services: 60% of Billed Charges	Duodenal Switch: 3 \| Gastric Banding: 2 \| Gastric Bypass: 3 \| Gastric Sleeve: 2		$5,000	100% of Billed Charges	Hospital: 70% of Billed Charges \| Professional: 60% of Billed Charges					50% of Billed Charges	Begins at Evaluation and Ends on the Day of Surgery	Begins on the Day of Surgery and Ends when the Number of Inlier Days and Applicable Outlier Days have Expired	Begins at Discharge and Ends One (1) Year Later		34.053691	-118.242766	89.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates		45% of Billed Charges		N/A		45% of Billed Charges	45% of Billed Charges	Included in Case Rate	Included in Case Rate			45% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from the end of Inlier Days and applicable Outlier Days		34.053691	-118.242766	857.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates		45% of Billed Charges		N/A		45% of Billed Charges	45% of Billed Charges	Included in Case Rate	Included in Case Rate			45% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from the end of Inlier Days and applicable Outlier Days		34.053691	-118.242766	857.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Government Rates		45% of Billed Charges		N/A		45% of Billed Charges	45% of Billed Charges	Included in Case Rate	Included in Case Rate			45% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from the end of Inlier Days and applicable Outlier Days		34.053691	-118.242766	857.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Heart	Heart	Adult	Government Rates		45% of Billed Charges				45% of Billed Charges	45% of Billed Charges			Included in Case Rate	Charges Included in Case Rate	45% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends upon Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	858.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Heart/Lung	Heart/Lung	Adult	Government Rates		45% of Billed Charges				45% of Billed Charges	45% of Billed Charges			Included in Case Rate	Charges Included in Case Rate	45% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends upon Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	859.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Kidney	Kidney	Adult	Government Rates		45% of Billed Charges				45% of Billed Charges	45% of Billed Charges			Included in Case Rate	Charges Included in Case Rate	45% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends upon Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	860.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates		45% of Billed Charges				45% of Billed Charges	45% of Billed Charges			Included in Case Rate	Charges Included in Case Rate	45% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends upon Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	861.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Liver	Liver	Adult	Government Rates		45% of Billed Charges				45% of Billed Charges	45% of Billed Charges			Included in Case Rate	Charges Included in Case Rate	45% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends upon Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	862.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Lung	Lung	Adult	Government Rates		45% of Billed Charges				45% of Billed Charges	45% of Billed Charges			Included in Case Rate	Charges Included in Case Rate	45% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends upon Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	863.pdf
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Pancreas	Pancreas	Adult	Government Rates		45% of Billed Charges				45% of Billed Charges	45% of Billed Charges			Included in Case Rate	Charges Included in Case Rate	45% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends upon Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	864.pdf
CHI St Luke's Health Baylor College of Medicine Medical Center	Transplant	Houston	TX	Liver	Liver	Adult	Member's Choice		Cadaveric Donor Hospital: $130,000 \| Cadaveric Donor Professional: 70% of Billed Charges \| Living Donor Hospital: $115,000 \| Cadaveric Donor Professional: 70% of Billed Charges	20		$2,900 ICU/CCU \| $2,500 Med/Surg	90% of Billed Charges	Hospital: 70% of Billed Charges \| Professional: 70% of Billed Charges \| Cardiovascular Care: 80% of Billed Charges			Included in Case Rate	(Revenue Codes: 275, 276, 278, 279) Reimbursed at 60% of Billed Charges \| (Revenue Code: 624 - Category B) Reimbursed at 100% of Billed Charges	60% of Billed Charges in Excess of the Threshold (166 Times the Case Rate Plus any Applicable Per Diems)	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	92.pdf
CHI St Luke's Health Baylor College of Medicine Medical Center	Transplant	Houston	TX	Pancreas	Pancreas	Adult	Member's Choice		Hospital: $70,000 \| Professional: 70% of Billed Charges	15		$3,150 ICU/CCU \| $2,500 Med/Surg	90% of Billed Charges	Hospital: 70% of Billed Charges \| Professional: 70% of Billed Charges \| Cardiovascular Care: 80% of Billed Charges			Included in Case Rate	(Revenue Codes: 275, 276, 278, 279) Reimbursed at 60% of Billed Charges \| (Revenue Code: 624 - Category B) Reimbursed at 100% of Billed Charges	60% of Billed Charges in Excess of the Threshold (166 Times the Case Rate Plus any Applicable Per Diems)	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	93.pdf
CHI St Luke's Health Baylor College of Medicine Medical Center	Transplant	Houston	TX	Heart	Heart	Adult	Member's Choice		Hospital: $115,000 \| Professional: 70% of Billed Charges	20		$2,900 ICU/CCU \| $2,900 Med/Surg	90% of Billed Charges	Hospital: 70% of Billed Charges \| Professional: 70% of Billed Charges \| Cardiovascular Care: 80% of Billed Charges			Included in Case Rate	(Revenue Codes: 275, 276, 278, 279) Reimbursed at 60% of Billed Charges \| (Revenue Code: 624 - Category B) Reimbursed at 100% of Billed Charges	60% of Billed Charges in Excess of the Threshold (166 Times the Case Rate Plus any Applicable Per Diems)	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	94.pdf
CHI St Luke's Health Baylor College of Medicine Medical Center	Destination VAD	Houston	TX	Destination VAD	Destination VAD				Surgical Event: 60% of Billed Charges	N/A		Inpatient Per Diem: $3,400	90% of Billed Charges	70% of Billed Charges \| VAD Maintenance & Supplies: 60% of Billed Charges				Revenue Codes 275, 276, 278, 279: 60% of Billed Charges \| Revenue Code 624 - Category B: 100% of Billed Charges \| Revenue Code 624 - Category B: 60% of Billed Charges	Inpatient Stay: 60% of Billed Charges	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		43.0578056	-88.1078546	94.pdf
CHI St Luke's Health Baylor College of Medicine Medical Center	Transplant	Houston	TX	Kidney	Kidney	Adult	Member's Choice		Cadaveric Donor Hospital: $55,000 \| Cadaveric Donor Professional: 70% of Billed Charges \| Living Donor Hospital: $40,000 \| Cadaveric Donor Professional: 70% of Billed Charges	Cadaveric Donor: 10 \| Living Donor: 20		$2,900 ICU/CCU \| $2,500 Med/Surg	90% of Billed Charges	Hospital: 70% of Billed Charges \| Professional: 70% of Billed Charges \| Cardiovascular Care: 80% of Billed Charges			Included in Case Rate	(Revenue Codes: 275, 276, 278, 279) Reimbursed at 60% of Billed Charges \| (Revenue Code: 624 - Category B) Reimbursed at 100% of Billed Charges	60% of Billed Charges in Excess of the Threshold (166 Times the Case Rate Plus any Applicable Per Diems)	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	95.pdf
CHI St Luke's Health Baylor College of Medicine Medical Center	Transplant	Houston	TX	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	Single Lung Hospital: $155,000 \| Single Lung Professional: 70% of Billed Charges \| Bilateral Lung Hospital: $185,000 \| Bilateral Lung Professional: 70% of Billed Charges	15		$3,500 Med/Surg \| $3,500 ICU/CCU	90% of Billed Charges	Hospital: 70% of Billed Charges \| Professional: 70% of Billed Charges \| Cardiovascular Care: 80% of Billed Charges			Living Donor Reimbursed at 50% of Billed Charges \| Cadaveric Organ Acquisition Included in the Case Rate	N/A	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	96.pdf
CHI St Luke's Health Baylor College of Medicine Medical Center	Bariatric	Houston	TX	Bariatric	Bariatric				DRG 619 Hospital: $16,359 \| DRG 619 Professional: 70% of Billed Charges \| DRG 620 Hospital: $11,452 \| DRG 620 Professional: 70% of Billed Charges \| DRG 621 Hospital: $9,995 \| DRG 621 Professional: 70% of Billed Charges \| DRG 987 Hospital: $16,878 \| DRG 987 Professional: 70% of Billed Charges \| DRG 988 Hospital: $11,923 \| DRG 988 Professional: 70% of Billed Charges \| DRG 989 Hospital: $9,659 \| DRG 989 Professional: 70% of Billed Charges	DRG 619: 3 \| DRG 620: 2 \| DRG 621: 2 \| DRG 987: 3 \| DRG 988: 2 \| DRG 989: 2		Hospital: $2,500 \| Professional: 70% of Billed Charges	N/A	Hospital: 70% of Billed Charges \| Professional: 70% of Billed Charges					N/A	Begins at Evaluation	Begins on the Day of Surgery and Ends when the Number of Inlier Days and Applicable Outlier Days have Expired	Begins at Discharge and Ends One (1) Year Later		43.0578056	-88.1078546	97.pdf
Children's Hospital Colorado	Transplant	Aurora	CO	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$175,000	35	Transplant Case Rate Paid at 65% of Billed Charges	$5,250	N/A	75% of Billed Charges	Included in Case Rate	Included in Case Rate			65% of Billed Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends when iInlier and any Applicable Outlier Days have Expired	Ends 90 Days from Discharge		43.0578056	-88.1078546	98.pdf
Children's Hospital Colorado	Transplant	Aurora	CO	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$200,000	35	Transplant Case Rate Paid at 65% of Billed Charges	$5,250	N/A	75% of Billed Charges	Included in Case Rate	Included in Case Rate			65% of Billed Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends when iInlier and any Applicable Outlier Days have Expired	Ends 90 Days from Discharge		43.0578056	-88.1078546	98.pdf
Children's Hospital Colorado	Transplant	Aurora	CO	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$145,000	31	Transplant Case Rate Paid at 65% of Billed Charges	$5,250	N/A	75% of Billed Charges	Included in Case Rate	Included in Case Rate			65% of Billed Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends when iInlier and any Applicable Outlier Days have Expired	Ends 90 Days from Discharge		43.0578056	-88.1078546	98.pdf
Children's Hospital Colorado	Transplant	Aurora	CO	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Pediatric	Programs of Excellence		$250,000	30 for each Auto	Transplant Case Rate Paid at 65% of Billed Charges	$5,250	N/A	75% of Billed Charges	Included in Case Rate	Included in Case Rate			65% of Billed Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends when iInlier and any Applicable Outlier Days have Expired	Ends 90 Days from Discharge		43.0578056	-88.1078546	98.pdf
Children's Hospital Colorado	Transplant	Aurora	CO	Heart	Heart	Pediatric	Programs of Excellence		$175,000	20		$5,250	N/A	75% of Billed Charges			Included in Case Rate	Included in Case Rate	65% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge. If Patient is Inpatient when Inlier Days have Expired Then Outlier Days apply until Discharge	Ends 90 Days from Discharge		43.0578056	-88.1078546	99.pdf
Children's Hospital Colorado	Transplant	Aurora	CO	Kidney	Kidney	Pediatric	Programs of Excellence		$62,000	14		$5,250	N/A	75% of Billed Charges			Included in Case Rate	Included in Case Rate	65% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge. If Patient is Inpatient when Inlier Days have Expired Then Outlier Days apply until Discharge	Ends 90 Days from Discharge		43.0578056	-88.1078546	100.pdf
Children's Hospital Colorado	Transplant	Aurora	CO	Liver	Liver	Pediatric	Programs of Excellence		$174,000	25		$5,250	N/A	75% of Billed Charges			Included in Case Rate	Included in Case Rate	65% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge. If Patient is Inpatient when Inlier Days have Expired Then Outlier Days apply until Discharge	Ends 90 Days from Discharge		43.0578056	-88.1078546	101.pdf
Children's Hospital Colorado	Congenital Heart Defect	Aurora	CO	Congenital Heart Defect	Congenital Heart Defect				Surgical Event Hospital: 65% of Billed Charges \| Surgical Event Professional: 75% of Billed Charges \| (Med/Surg) Hospital: 65% of Billed Charges \| (Med/Surg) Professional: 75% of Billed Charges \| (NICU/PICU) Hospital: $2,970 Per Diem \| (NICU/PICU) Professional: 75% of Billed Charges \| (ECMO) Hospital: $7,842 Per Diem \| (ECMO) Professional: 75% of Billed Charges	N/A		N/A	N/A	Hospital: 80% of Billed Charges \| Professional: 75% of Billed Charges				105% of Billed Charges	65% of Billed Charges	Begins on the Date of Referral to INTERLINK	Begins Upon Referral to INTERLINK &/Or when Patient is Admitted to Facility	Coverage Remains Active Until Patient No Longer Requires Pediatric Heart Services		43.0578056	-88.1078546	102.pdf
Children's Hospital Colorado	Transplant	Aurora	CO	Heart	Heart	Pediatric	Government Rates		$224,055	20		$5,975	N/A	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	Heart Assist Devices Included in Pre-Transplant or Transplant Event, as Applicable.	60% of Billed Charges	Begins at Evaluation	Beginning One (1) Day Prior to Transplant, Ending the Day of Discharge	Ends One (1) Year from Transplant Date		43.0578056	-88.1078546	103.pdf
Children's Hospital Colorado	Transplant	Aurora	CO	Kidney	Kidney	Pediatric	Government Rates		$82,154	14		$5,975	N/A	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	Heart Assist Devices Included in Pre-Transplant or Transplant Event, as Applicable.	60% of Billed Charges	Begins at Evaluation	Beginning One (1) Day Prior to Transplant, Ending the Day of Discharge	Ends One (1) Year from Transplant Date		43.0578056	-88.1078546	104.pdf
Children's Hospital Colorado	Transplant	Aurora	CO	Liver	Liver	Pediatric	Government Rates		$238,992	25		$5,975	N/A	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate		60% of Billed Charges	Begins at Evaluation	Beginning One (1) Day Prior to Transplant, Ending the Day of Discharge	Ends One (1) Year from Transplant Date		43.0578056	-88.1078546	105.pdf
Children's Hospital Colorado	Transplant	Aurora	CO	Blood/Marrow (Autologous)	Autologous	Pediatric	Government Rates		$194,181	35		$5,975	N/A	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Beginning on Day of Preparative Therapy, Ending when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	106.pdf
Children's Hospital Colorado	Transplant	Aurora	CO	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Government Rates		$243,473	35		$5,975	N/A	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Beginning on Day of Preparative Therapy, Ending when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	106.pdf
Children's Hospital Colorado	Transplant	Aurora	CO	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Government Rates		$276,335	35		$5,975	N/A	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Beginning on Day of Preparative Therapy, Ending when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	106.pdf
Children's Hospital Colorado	Transplant	Aurora	CO	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Pediatric	Government Rates		$291,272	35		$5,975	N/A	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Beginning on Day of Preparative Therapy, Ending when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	106.pdf
Children's Hospital Los Angeles	Bariatric	Los Angeles	CA	Bariatric	Bariatric				Gastric Banding: $17,000 \| Gastric Bypass: $19,000 \| Gastric Sleeve: $15,000 \| Duodenal Switch: $21,000 \| All Professional Services: 60% of Billed Charges	Gastric Banding: 2 \| Gastric Bypass: 3 \| Gastric Sleeve: 2 \| Duodenal Switch: 3		Hospital: $3,500 Med/Surg \| Hospital: $7,500 ICU/CCU \| Professional: 60% of Billed Charges	90% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 60% of Billed Charges					N/A	Begins at Evaluation and Ends on the Day of Surgery	Begins on the Day of Surgery and Ends when the Number of Inlier Days and Applicable Outlier Days have Expired	Begins at Discharge and Ends One (1) Year Later		34.053691	-118.242766	107.pdf
Children's Hospital Los Angeles	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Member's Choice		Hospital: $178,000 \| Professional Match: $19,630 \| Professional Partial Match: $28,200 \| Professional Haploidentical T-Cell Depleted: $31,100	45	N/A	Hospital: $2,750 Med/Surg \| Hospital: $5,500 ICU/CCU \| Professional: 60% of Billed Charges	90% of Billed Charges	Hospital Inpatient: Reimbursed at the Lesser of 90% of Billed Charges or a Per Diem of $2,750 Med/Surg or $5,500 ICU/CCU \| Hospital Outpatient Services and Supplies: Shall be Reimbursed at 75% of Billed Charges \| Professional Inpatient Services and Supplies: Shall be Reimbursed at 60% of Billed Charges \| Professional Outpatient Services and Supplies: Shall be Reimbursed at 70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Hospital: 50% of Billed Charges \| Professional: -N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		34.053691	-118.242766	108.pdf
Children's Hospital Los Angeles	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Member's Choice		Hospital: $230,000 \| Professional: $32,100	50	N/A	Hospital: $2,750 Med/Surg \| Hospital: $5,500 ICU/CCU \| Professional: 60% of Billed Charges	90% of Billed Charges	Hospital Inpatient: Reimbursed at the Lesser of 90% of Billed Charges or a Per Diem of $2,750 Med/Surg or $5,500 ICU/CCU \| Hospital Outpatient Services and Supplies: Shall be Reimbursed at 75% of Billed Charges \| Professional Inpatient Services and Supplies: Shall be Reimbursed at 60% of Billed Charges \| Professional Outpatient Services and Supplies: Shall be Reimbursed at 70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Hospital: 50% of Billed Charges \| Professional: N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		34.053691	-118.242766	108.pdf
Children's Hospital Los Angeles	Transplant	Los Angeles	CA	Blood/Marrow (Autologous)	Autologous	Pediatric	Member's Choice		Hospital: $125,000 \| Professional w/o Chemo: $11,687 \| Professional w/ Chemo: $22,800	30	N/A	Hospital: $2,750 Med/Surg \| Hospital: $5,500 ICU/CCU \| Professional: 60% of Billed Charges	90% of Billed Charges	Hospital Inpatient: Reimbursed at the Lesser of 90% of Billed Charges or a Per Diem of $2,750 Med/Surg or $5,500 ICU/CCU \| Hospital Outpatient Services and Supplies: Shall be Reimbursed at 75% of Billed Charges \| Professional Inpatient Services and Supplies: Shall be Reimbursed at 60% of Billed Charges \| Professional Outpatient Services and Supplies: Shall be Reimbursed at 70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Hospital: 50% of Billed Charges \| Professional: N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		34.053691	-118.242766	108.pdf
Children's Hospital Los Angeles	Transplant	Los Angeles	CA	Blood/Marrow (Cord Blood)	Cord Blood	Pediatric	Member's Choice		Hospital: $250,000 \| Professional: $32,100	50	N/A	Hospital: $2,750 Med/Surg \| Hospital: $5,500 ICU/CCU \| Professional: 60% of Billed Charges	90% of Billed Charges	Hospital Inpatient: Reimbursed at the Lesser of 90% of Billed Charges or a Per Diem of $2,750 Med/Surg or $5,500 ICU/CCU \| Hospital Outpatient Services and Supplies: Shall be Reimbursed at 75% of Billed Charges \| Professional Inpatient Services and Supplies: Shall be Reimbursed at 60% of Billed Charges \| Professional Outpatient Services and Supplies: Shall be Reimbursed at 70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Hospital: 50% of Billed Charges \| Professional: N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Transplant Date		34.053691	-118.242766	108.pdf
Children's Hospital Los Angeles	Transplant	Los Angeles	CA	Heart	Heart	Pediatric	Programs of Excellence		Hospital: $171,000 \| Professional: $17,420	Hospital: 26 \| Professional: 21		Hospital: $2,750 Med/Surg \| Hospital: $5,500 ICU/CCU \| Professional: 60% of Billed Charges	90% of Billed Charges	Hospital Inpatient: Reimbursed at the Lesser of 90% of Billed Charges or a Per Diem of $2,750 Med/Surg or $5,500 ICU/CCU \| Hospital Outpatient Services and Supplies: Shall be Reimbursed at 75% of Billed Charges \| Professional Inpatient Services and Supplies: Shall be Reimbursed at 60% of Billed Charges \| Professional Outpatient Services and Supplies: Shall be Reimbursed at 70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	Hospital: 50% of Billed Charges Professional: N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	109.pdf
Children's Hospital Los Angeles	Transplant	Los Angeles	CA	Kidney	Kidney	Pediatric	Programs of Excellence		Hospital Cadaveric Donor: $69,550 \| Hospital Living Donor: $72,100.00 \| Professional Cadaveric Donor: $75,000 \| Professional Living Donor: $7,000	Hospital Cadaveric Donor: 10 \| Hospital Living Donor: 10 \| Professional Cadaveric Donor: 14 \| Professional Living Donor: 10		Hospital: $2,750 Med/Surg Hospital: $5,500 ICU/CCU Professional: 60% of Billed Charges	90% of Billed Charges	Hospital Inpatient: Reimbursed at the Lesser of 90% of Billed Charges or a Per Diem of $2,750 Med/Surg or $5,500 ICU/CCU \| Hospital Outpatient Services and Supplies: Shall be Reimbursed at 75% of Billed Charges \| Professional Inpatient Services and Supplies: Shall be Reimbursed at 60% of Billed Charges \| Professional Outpatient Services and Supplies: Shall be Reimbursed at 70% of Billed Charges			Included in Case Rate	N/A	Hospital: 50% of Billed Charges Professional: N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	110.pdf
Children's Hospital Los Angeles	Transplant	Los Angeles	CA	Liver	Liver	Pediatric	Programs of Excellence		Hospital Cadaveric Donor: $141,000\| Hospital Living Donor: $107,205 \| Professional Cadaveric Donor: $26,600 \| Professional Living Donor: $31,600	Hospital Cadaveric Donor: 20 \| Hospital Living Donor: 20 \| Professional Cadaveric Donor: 21 \| Professional Living Donor: 21		Hospital: $2,750 Med/Surg \| Hospital: $5,500 ICU/CCU \| Professional: 60% of Billed Charges	90% of Billed Charges	Hospital Inpatient: Reimbursed at the Lesser of 90% of Billed Charges or a Per Diem of $2,750 Med/Surg or $5,500 ICU/CCU \| Hospital Outpatient Services and Supplies: Shall be Reimbursed at 75% of Billed Charges \| Professional Inpatient Services and Supplies: Shall be Reimbursed at 60% of Billed Charges \| Professional Outpatient Services and Supplies: Shall be Reimbursed at 70% of Billed Charges	N/A	N/A	Included in Case Rate	N/A	Hospital: 50% of Billed Charges \| Professional: N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	111.pdf
Children's Hospital Los Angeles	Cellular Immunotherapy	Los Angeles	CA	Cellular Immunotherapy	Cellular Immunotherapy				Charges $0 - $500,000 Pay at 60% of Billed \| Charges $500,001 - $1,000,000 Pay at 50% \| Charges $1,000,001 and Above Pay at 40% \| Drug Cost: 105% of Wholesale Acquisition Cost (WAC)	N/A		N/A	N/A	60% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends One (1) Year from Discharge		34.053691	-118.242766	112.pdf
Children's Hospital Los Angeles	Congenital Heart Defect	Los Angeles	CA	Congenital Heart Defect	Congenital Heart Defect				Surgical Event: 60% of Billed Charges \| Inpatient (Med/Surg) Hospital: $6,268 Per Diem \| Inpatient (Med/Surg) Professional: 60% of Billed Charges \| Inpatient (NICU/PICU) Hospital: $11,641 Per Diem \| Inpatient (NICU/PICU) Professional 60% of Billed Charges \| Inpatient (CICU): $13,431 Per Diem \| Inpatient (ECMO): 60% of Billed Charges	N/A		N/A	100% of Billed Charges	75% of Billed Charges				46% of Billed Charges	60% of Billed Charges	Begins on the Date of Referral to INTERLINK	Begins Upon Referral to INTERLINK &/Or when Patient is Admitted to Facility	Coverage Remains Active Until Patient No Longer Requires Pediatric Heart Services		34.053691	-118.242766	113.pdf
Children's Hospital of Philadelphia	Transplant	Philadelphia	PA	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		Hospital: $269,694 \| Professional: 75% of Billed Charges	N/A		N/A	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			65% of Billed Charges in Excess of the Stop Loss Threshold ($416,830)	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	114.pdf
Children's Hospital of Philadelphia	Transplant	Philadelphia	PA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		Hospital: $371,134 \| Professional: 75% of Billed Charges	N/A		N/A	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			65% of Billed Charges in Excess of the Stop Loss Threshold ($577,426)	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	114.pdf
Children's Hospital of Philadelphia	Transplant	Philadelphia	PA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		Hospital: $451,379 \| Professional: 75% of Billed Charges	N/A		N/A	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			65% of Billed Charges in Excess of the Stop Loss Threshold ($695,459)	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	114.pdf
Children's Hospital of Philadelphia	Transplant	Philadelphia	PA	Heart	Heart	Pediatric	Programs of Excellence		Hospital: $390,080 \|Professional: 75% of Billed Charges	N/A		N/A	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	65% of Billed Charges in Excess of the Stop Loss Threshold ($601,840)	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	115.pdf
Children's Hospital of Philadelphia	Transplant	Philadelphia	PA	Heart/Lung	Heart/Lung	Pediatric	Member's Choice		Hospital: $434,661 \| Professional: 75% of Billed Charges	N/A		N/A	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	65% of Billed Charges in Excess of the Stop Loss Threshold ($668,710)	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	116.pdf
Children's Hospital of Philadelphia	Transplant	Philadelphia	PA	Kidney	Kidney	Pediatric	Programs of Excellence		Hospital: $190,582 \| Professional: 75% of Billed Charges	N/A		N/A	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	65% of Billed Charges in Excess of the Stop Loss Threshold ($292,003)	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	117.pdf
Children's Hospital of Philadelphia	Transplant	Philadelphia	PA	Liver	Liver	Pediatric	Programs of Excellence		Hospital: $300,919 \| Professional: 75% of Billed Charges	N/A		N/A	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	65% of Billed Charges in Excess of the Stop Loss Threshold ($463,639)	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	118.pdf
Children's Hospital of Philadelphia	Transplant	Philadelphia	PA	Lung	Lung	Pediatric	Programs of Excellence		Hospital: $412,371 \| Professional: 75% of Billed Charges	N/A		N/A	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	65% of Billed Charges in Excess of the Stop Loss Threshold ($635,275)	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	119.pdf
Children's Hospital of Philadelphia	Cellular Immunotherapy	Philadelphia	PA	Cellular Immunotherapy	Cellular Immunotherapy				Hospital: 55% of Billed Charges \| Professional: 75% of Billed Charges \| Drug Cost: 100% of Wholesale Acquisition Cost (WAC)	N/A		N/A	N/A	Hospital: 60% of Billed Charges \| Professional: 75% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends 365 Days from Discharge		43.0578056	-88.1078546	120.pdf
Children's Hospital of Wisconsin	Transplant	Milwaukee	WI	Blood/Marrow (Cord Blood)	Cord Blood	Pediatric	Programs of Excellence		$198,000	35		$3,600 Med/Surg \| $3,600 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends Six (6) Months from Transplant Date		43.0578056	-88.1078546	121.pdf
Children's Hospital of Wisconsin	Transplant	Milwaukee	WI	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$150,000	30		$3,600 Med/Surg \| $3,600 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends Six (6) Months from Transplant Date		43.0578056	-88.1078546	121.pdf
Children's Hospital of Wisconsin	Transplant	Milwaukee	WI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$198,000	35		$3,600 Med/Surg \| $3,600 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends Six (6) Months from Transplant Date		43.0578056	-88.1078546	121.pdf
Children's Hospital of Wisconsin	Transplant	Milwaukee	WI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$204,000	40		$3,600 Med/Surg \| $3,600 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends Six (6) Months from Transplant Date		43.0578056	-88.1078546	121.pdf
Children's Hospital of Wisconsin	Transplant	Milwaukee	WI	Heart	Heart	Pediatric	Programs of Excellence		$186,000	25		$4,200 Med/Surg \| $4,200 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and Applicable Outlier Days have Expired	Ends Six (6) Months from Transplant Date		43.0578056	-88.1078546	122.pdf
Children's Hospital of Wisconsin	Transplant	Milwaukee	WI	Kidney	Kidney	Pediatric	Member's Choice		$84,000	12		$4,200 Med/Surg \| $4,200 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and Applicable Outlier Days have Expired	Ends Six (6) Months from Transplant Date		43.0578056	-88.1078546	123.pdf
Children's Hospital of Wisconsin	Transplant	Milwaukee	WI	Liver	Liver	Pediatric	Member's Choice		$186,000	30		$4,200 Med/Surg \| $4,200 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and Applicable Outlier Days have Expired	Ends Six (6) Months from Transplant Date		43.0578056	-88.1078546	124.pdf
Children's Hospital of Wisconsin	Transplant	Milwaukee	WI	Lung	Lung	Pediatric	Member's Choice		$192,000	30		$4,200 Med/Surg \| $4,200 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and Applicable Outlier Days have Expired	Ends Six (6) Months from Transplant Date		43.0578056	-88.1078546	867.pdf
Children's Hospital of Wisconsin	Congenital Heart Defect	Milwaukee	WI	Congenital Heart Defect	Congenital Heart Defect				75% of Billed Charges	N/A		N/A	N/A	75% of Billed Charges				75% of Billed Charges	N/A	Begins on the Date of Referral to INTERLINK	Begins Upon Referral to INTERLINK &/Or when Patient is Admitted to Facility	Coverage Remains Active Until Patient No Longer Requires Pediatric Heart Services		43.0578056	-88.1078546	125.pdf
Children's Medical Center of Dallas	Transplant	Dallas	TX	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		Hospital: $110,000 \| Professional: 70% of Billed Charges	35		$2,500 Med/Surg \| $4,800 ICU/CCU	90% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			71% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	126.pdf
Children's Medical Center of Dallas	Transplant	Dallas	TX	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		Hospital: $150,000 \| Professional: 70% of Billed Charges	45		$2,500 Med/Surg \| $4,800 ICU/CCU	90% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			71% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	126.pdf
Children's Medical Center of Dallas	Transplant	Dallas	TX	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		Hospital: $170,000 \| Professional: 70% of Billed Charges	50		$2,500 Med/Surg \| $4,800 ICU/CCU	90% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			71% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		43.0578056	-88.1078546	126.pdf
Children's Medical Center of Dallas	Transplant	Dallas	TX	Heart	Heart	Pediatric	Programs of Excellence		Hospital: $160,000 \| Professional: 70% of Billed Charges	26		$2,500 Med/Surg \| $5,500 ICU/CCU	90% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 70% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	71% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	127.pdf
Children's Medical Center of Dallas	Transplant	Dallas	TX	Intestine	Intestine	Pediatric	Member's Choice		Hospital: $275,000 \| Professional: 70% of Billed Charges	46		$2,500 Med/Surg \| $5,500 ICU/CCU	90% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 70% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	71% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	128.pdf
Children's Medical Center of Dallas	Transplant	Dallas	TX	Kidney	Kidney	Pediatric	Programs of Excellence		Hospital: $65,000 \| Professional: 70% of Billed Charges	16		$2,500 Med/Surg \| $4,800 ICU/CCU	90% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 70% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	71% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	129.pdf
Children's Medical Center of Dallas	Transplant	Dallas	TX	Liver	Liver	Pediatric	Programs of Excellence		Cadaveric Donor: Hospital: $130,875 \| Professional: 70% of Billed Charges \| Living Donor: Hospital: $97,500 \| Professional: 70% of Billed Charges	24		$2,500 Med/Surg \| $4,800 ICU/CCU	90% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 70% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	71% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	130.pdf
Children's Medical Center of Dallas	Transplant	Dallas	TX	Heart/Kidney	Heart/Kidney	Pediatric	Member's Choice		Hospital: $192,500 \| Professional: 70% of Billed Charges	26		$2,500 Med/Surg \| $5,500 ICU/CCU	90% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 70% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	71% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	131.pdf
Children's Medical Center of Dallas	Congenital Heart Defect	Dallas	TX	Congenital Heart Defect	Congenital Heart Defect				Hospital: 71% of Billed Charges \| Professional: 70% of Billed Charges	N/A		N/A	N/A	Hospital: 71% of Billed Charges \| Professional: 70% of Billed Charges				N/A	N/A	Begins on the Date of Referral to INTERLINK	Begins Upon Referral to INTERLINK &/Or when Patient is Admitted to Facility	Coverage Remains Active Until Patient No Longer Requires Pediatric Heart Services		43.0578056	-88.1078546	132.pdf
Children's National Hospital	Transplant	Washington, DC	DC	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		55% of Billed Charges					55% of Billed Charges	55% of Billed Charges			Reimbursed at Invoice Cost		Begins at Evlauation	Begins one day prior to ablative therapy	Ends 365 Days from Discharge		38.895037	-77.036543	133.pdf
Children's National Hospital	Transplant	Washington, DC	DC	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		55% of Billed Charges					55% of Billed Charges	55% of Billed Charges			Reimbursed at Invoice Cost		Begins at Evlauation	Begins one day prior to ablative therapy	Ends 365 Days from Discharge		38.895037	-77.036543	133.pdf
Children's National Hospital	Transplant	Washington, DC	DC	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		55% of Billed Charges					55% of Billed Charges	55% of Billed Charges			Reimbursed at Invoice Cost		Begins at Evlauation	Begins one day prior to ablative therapy	Ends 365 Days from Discharge		38.895037	-77.036543	133.pdf
Children's National Hospital	Transplant	Washington, DC	DC	Kidney	Kidney	Pediatric	Programs of Excellence		55% of Billed Charges					55% of Billed Charges			100% of the Organ Procurement Invoice Cost	Reimbursed at Invoice Cost		Begins at Evlauation	Begins one day prior to transplant	Ends 365 Days from Discharge		38.895037	-77.036543	134.pdf
Children's National Hospital	Transplant	Washington, DC	DC	Heart	Heart	Pediatric	Programs of Excellence		55% of Billed Charges					55% of Billed Charges			100% of the Organ Procurement Invoice Cost	Reimbursed at Invoice Cost		Begins at Evlauation	Begins one day prior to transplant	Ends 365 Days from Discharge		38.895037	-77.036543	134.pdf
Children's National Hospital (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	Washington, DC	DC	Blood/Marrow (Autologous)	Autologous	Pediatric	Government Rates		The State of Maryland or Washington D.C: 103% of Medicaid Fee-For-Service Rate \| Outside the State of Maryland or Washington D.C: 125% of Medicaid Fee-For-Service Rate					The State of Maryland or Washington D.C: 103% of Medicaid Fee-For-Service Rate \| Outside the State of Maryland or Washington D.C: 125% of Medicaid Fee-For-Service Rate	The State of Maryland or Washington D.C: 103% of Medicaid Fee-For-Service Rate \| Outside the State of Maryland or Washington D.C: 125% of Medicaid Fee-For-Service Rate	Included in the Case Rate		Reimbursed at Invoice Cost		Begins at Evlauation	Begins one day prior to ablative therapy	Ends 365 Days from Discharge		38.895037	-77.036543	135.pdf
Children's National Hospital (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	Washington, DC	DC	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Government Rates		The State of Maryland or Washington D.C: 103% of Medicaid Fee-For-Service Rate \| Outside the State of Maryland or Washington D.C: 125% of Medicaid Fee-For-Service Rate					The State of Maryland or Washington D.C: 103% of Medicaid Fee-For-Service Rate \| Outside the State of Maryland or Washington D.C: 125% of Medicaid Fee-For-Service Rate	The State of Maryland or Washington D.C: 103% of Medicaid Fee-For-Service Rate \| Outside the State of Maryland or Washington D.C: 125% of Medicaid Fee-For-Service Rate	Included in the Case Rate		Reimbursed at Invoice Cost		Begins at Evlauation	Begins one day prior to ablative therapy	Ends 365 Days from Discharge		38.895037	-77.036543	135.pdf
Children's National Hospital (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	Washington, DC	DC	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Government Rates		The State of Maryland or Washington D.C: 103% of Medicaid Fee-For-Service Rate \| Outside the State of Maryland or Washington D.C: 125% of Medicaid Fee-For-Service Rate					The State of Maryland or Washington D.C: 103% of Medicaid Fee-For-Service Rate \| Outside the State of Maryland or Washington D.C: 125% of Medicaid Fee-For-Service Rate	The State of Maryland or Washington D.C: 103% of Medicaid Fee-For-Service Rate \| Outside the State of Maryland or Washington D.C: 125% of Medicaid Fee-For-Service Rate	Included in the Case Rate		Reimbursed at Invoice Cost		Begins at Evlauation	Begins one day prior to ablative therapy	Ends 365 Days from Discharge		38.895037	-77.036543	135.pdf
Children's National Hospital (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	Washington, DC	DC	Kidney	Kidney	Pediatric	Government Rates		The State of Maryland or Washington D.C: 103% of Medicaid Fee-For-Service Rate \| Outside the State of Maryland or Washington D.C: 125% of Medicaid Fee-For-Service Rate					The State of Maryland or Washington D.C: 103% of Medicaid Fee-For-Service Rate \| Outside the State of Maryland or Washington D.C: 125% of Medicaid Fee-For-Service Rate			100% of the Organ Procurement Invoice Cost	Reimbursed at Invoice Cost		Begins at Evlauation	Begins one day prior to transplant	Ends 365 Days from Discharge		38.895037	-77.036543	136.pdf
Children's National Hospital (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	Washington, DC	DC	Heart	Heart	Pediatric	Government Rates		The State of Maryland or Washington D.C: 103% of Medicaid Fee-For-Service Rate \| Outside the State of Maryland or Washington D.C: 125% of Medicaid Fee-For-Service Rate					The State of Maryland or Washington D.C: 103% of Medicaid Fee-For-Service Rate \| Outside the State of Maryland or Washington D.C: 125% of Medicaid Fee-For-Service Rate			100% of the Organ Procurement Invoice Cost	Reimbursed at Invoice Cost		Begins at Evlauation	Begins one day prior to transplant	Ends 365 Days from Discharge		38.895037	-77.036543	137.pdf
Cincinnati Children's Hospital Medical Center	Transplant	Cincinnati	OH	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$185,000	40		$2,500 Med/Surg \| $3,500 ICU/CCU	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy or, if no Ablative Therapy One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.9828667	-83.1312539	138.pdf
Cincinnati Children's Hospital Medical Center	Transplant	Cincinnati	OH	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$220,000	45		$2,500 Med/Surg \| $3,500 ICU/CCU	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy or, if no Ablative Therapy One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.9828667	-83.1312539	138.pdf
Cincinnati Children's Hospital Medical Center	Transplant	Cincinnati	OH	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$142,000	35		$2,500 Med/Surg \| $3,500 ICU/CCU	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy or, if no Ablative Therapy One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.9828667	-83.1312539	138.pdf
Cincinnati Children's Hospital Medical Center	Transplant	Cincinnati	OH	Heart	Heart	Pediatric	Member's Choice		$169,000	20		$2,500 Med/Surg \| $3,500 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	105% of Invoice Cost	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.9828667	-83.1312539	139.pdf
Cincinnati Children's Hospital Medical Center	Transplant	Cincinnati	OH	Heart/Lung	Heart/Lung	Pediatric	Member's Choice		$269,500	35		$2,500 Med/Surg \| $3,500 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	105% of Invoice Cost	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.9828667	-83.1312539	140.pdf
Cincinnati Children's Hospital Medical Center	Transplant	Cincinnati	OH	Intestine	Intestine	Pediatric	Member's Choice		70% of Billed Charges	N/A		N/A	N/A	80% of Billed Charges			Included in Case Rate	105% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.9828667	-83.1312539	141.pdf
Cincinnati Children's Hospital Medical Center	Transplant	Cincinnati	OH	Intestine/Liver	Intestine/Liver	Pediatric	Member's Choice		70% of Billed Charges	N/A		N/A	N/A	80% of Billed Charges			Included in Case Rate	105% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.9828667	-83.1312539	142.pdf
Cincinnati Children's Hospital Medical Center	Transplant	Cincinnati	OH	Kidney	Kidney	Pediatric	Member's Choice		$78,000	12		$2,500 Med/Surg \| $3,500 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	105% of Invoice Cost	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.9828667	-83.1312539	143.pdf
Cincinnati Children's Hospital Medical Center	Transplant	Cincinnati	OH	Kidney/Liver	Kidney/Liver	Pediatric	Member's Choice		70% of Billed Charges	N/A		N/A	N/A	80% of Billed Charges			Included in Case Rate	105% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.9828667	-83.1312539	144.pdf
Cincinnati Children's Hospital Medical Center	Transplant	Cincinnati	OH	Liver	Liver	Pediatric	Member's Choice		$185,000	20		$2,500 Med/Surg \| $3,500 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	105% of Invoice Cost	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.9828667	-83.1312539	145.pdf
Cincinnati Children's Hospital Medical Center	Transplant	Cincinnati	OH	Lung	Lung	Pediatric	Programs of Excellence		$185,000	23		$2,500 Med/Surg \| $3,500 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	105% of Invoice Cost	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.9828667	-83.1312539	146.pdf
Cincinnati Children's Hospital Medical Center	Cellular Immunotherapy	Cincinnati	OH	Cellular Immunotherapy	Cellular Immunotherapy				$142,000 \| Drug Cost: 100% of Wholesale Acquisition Cost (WAC)	N/A		N/A	90% of Billed Charges	80% of Billed Charges					60% of Billed Charges	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends 365 Days from Discharge		39.136319	-84.6106124	147.pdf
Cincinnati Children's Hospital Medical Center	Destination VAD	Cincinnati	OH	Destination VAD	Destination VAD				Surgical Event: 70% of Billed Charges	N/A		70% of Billed Charges	N/A	80% of Billed Charges \| VAD Maintenance & Supplies: 105% of Invoice Cost				105% of Invoice Cost	N/A	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		39.136319	-84.6106124	148.pdf
Cincinnati Children's Hospital Medical Center	Congenital Heart Defect	Cincinnati	OH	Congenital Heart Defect	Congenital Heart Defect				Surgical Event Inpatient Services (ECMO): 70% of Billed Charges	N/A		N/A	N/A	80% of Billed Charges				105% of Billed Charges	N/A	Begins on the Date of Referral to INTERLINK	Begins Upon Referral to INTERLINK &/Or when Patient is Admitted to Facility	Coverage Remains Active Until Patient No Longer Requires Pediatric Heart Services		39.136319	-84.6106124	149.pdf
City of Hope National Medical Center	Transplant	Duarte	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceELITE	Hospital: $157,500 \| Professional: $19,000	Hospital: N/A \| Professional: 30	N/A	Hospital: N/A \|Professional: $400 Med/Surg \| Professional: $400 ICU/CCU	90% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 70% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: Included in Case Rate	Reimbursed at Invoice Cost + 10%			Hospital: 60% of Billed Charges \| Professional: 55% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends upon Discharge or the last Day of Infusion for an Outpatient Transplant	Ends One (1) Year from the End of the Transplant Phase		34.1579217	-117.9926429	150.pdf
City of Hope National Medical Center	Transplant	Duarte	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		Hospital: $157,500 \| Professional: $19,000	Hospital: N/A \| Professional: 30	N/A	Hospital: N/A \| Professional: $400 Med/Surg \| Professional: $400 ICU/CCU	90% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 70% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: Included in Case Rate	Reimbursed at Invoice Cost + 10%			Hospital: 60% of Billed Charges \| Professional: 55% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends upon Discharge or the last Day of Infusion for an Outpatient Transplant	Ends One (1) Year from the End of the Transplant Phase		34.1579217	-117.9926429	150.pdf
City of Hope National Medical Center	Transplant	Duarte	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		Hospital: $210,000 \| Professional: $23,805	Hospital: N/A \| Professional: 35	N/A	Hospital: N/A \| Professional: $450 Med/Surg Professional $450 ICU/CCU	90% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 70% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: Included in Case Rate	Reimbursed at Invoice Cost + 10%			Hospital: 60% of Billed Charges \| Professional: 55% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends upon Discharge or the last Day of Infusion for an Outpatient Transplant	Ends One (1) Year from the End of the Transplant Phase		34.1579217	-117.9926429	150.pdf
City of Hope National Medical Center	Transplant	Duarte	CA	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		Hospital: $115,000 \| Professional $15,500	N/A 20	N/A	Hospital: N/A \| Professional: $375 Med/Surg \| Professional: $375 ICU/CCU	90% of Billed Charges	Hospital 75% of Billed Charges Professional 70% of Billed Charges	Hospital - 75% of Billed Charges Professional Included in Case Rate	Reimbursed at Invoice Cost + 10%			Hospital 60% of Billed Charges Professional 55% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends upon Discharge or the last Day of Infusion for an Outpatient Transplant	Ends One (1) Year from the End of the Transplant Phase		34.1579217	-117.9926429	150.pdf
City of Hope National Medical Center	Transplant	Duarte	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceELITE	Hospital: $210,000 \| Professional: $23,805	Hospital: N/A \| Professional: 35	N/A	Hospital: N/A \|Professional: $450 Med/Surg \| Professional: $450 ICU/CCU	90% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 70% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: Included in Case Rate	Reimbursed at Invoice Cost + 10%			Hospital: 60% of Billed Charges \| Professional: 55% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends upon Discharge or the last Day of Infusion for an Outpatient Transplant	Ends One (1) Year from the End of the Transplant Phase		34.1579217	-117.9926429	150.pdf
City of Hope National Medical Center	Transplant	Duarte	CA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceELITE	Hospital: $115,000 \| Professional: $15,500	Hosptial: N/A \| Professional: 20	N/A	Hospital: N/A \| Professional: $375 Med/Surg \| Professional: $375 ICU/CCU	90% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 70% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: Included in Case Rate	Reimbursed at Invoice Cost + 10%			Hospital: 60% of Billed Charges \| Professional: 55% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends upon Discharge or the last Day of Infusion for an Outpatient Transplant	Ends One (1) Year from the End of the Transplant Phase		34.1579217	-117.9926429	150.pdf
City of Hope National Medical Center	Cellular Immunotherapy	Duarte	CA	Cellular Immunotherapy	Cellular Immunotherapy				75% of Billed Charges	N/A		N/A	N/A	75% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends 365 Days from Discharge		34.1578544	-117.975176	151.pdf
City of Hope National Medical Center	Cancer	Duarte	CA	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															34.1578544	-117.975176	152.pdf
Corewell Health Grand Rapids Hospitals (Spectrum Health)	Transplant	Grand Rapids	MI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$182,849	25		65% of Billed Charges	95% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			30% of Billed Charges	Begins at Evaluation	The Transplant Phase Begins on the Day of Preparative Regimen and Ends the Day of Discharge	Ends 365 Days from Discharge		42.9564627	-85.7301286	153.pdf
Corewell Health Grand Rapids Hospitals (Spectrum Health)	Transplant	Grand Rapids	MI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$213,327	25		65% of Billed Charges	95% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			30% of Billed Charges	Begins at Evaluation	The Transplant Phase Begins on the Day of Preparative Regimen and Ends the Day of Discharge	Ends 365 Days from Discharge		42.9564627	-85.7301286	153.pdf
Corewell Health Grand Rapids Hospitals (Spectrum Health)	Transplant	Grand Rapids	MI	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$121,899	25		65% of Billed Charges	95% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			30% of Billed Charges	Begins at Evaluation	The Transplant Phase Begins on the Day of Preparative Regimen and Ends the Day of Discharge	Ends 365 Days from Discharge		42.9564627	-85.7301286	153.pdf
Corewell Health Grand Rapids Hospitals (Spectrum Health)	Transplant	Grand Rapids	MI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$373,009	25		65% of Billed Charges	95% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			30% of Billed Charges	Begins at Evaluation	The Transplant Phase Begins on the Day of Preparative Regimen and Ends the Day of Discharge	Ends 365 Days from Discharge		42.9564627	-85.7301286	153.pdf
Corewell Health Grand Rapids Hospitals (Spectrum Health)	Transplant	Grand Rapids	MI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$373,009	25		65% of Billed Charges	95% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			30% of Billed Charges	Begins at Evaluation	The Transplant Phase Begins on the Day of Preparative Regimen and Ends the Day of Discharge	Ends 365 Days from Discharge		42.9564627	-85.7301286	153.pdf
Corewell Health Grand Rapids Hospitals (Spectrum Health)	Transplant	Grand Rapids	MI	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$158,835	25		65% of Billed Charges	95% of Billed Charges	70% of Billed Charges	Included in Case Rate, Unless Prior to Inlier Period, then Reimbursment Shall be at the Pre-Transplant Rate	Included in Case Rate			30% of Billed Charges	Begins at Evaluation	The Transplant Phase Begins on the Day of Preparative Regimen and Ends the Day of Discharge	Ends 365 Days from Discharge		42.9564627	-85.7301286	153.pdf
Corewell Health Grand Rapids Hospitals (Spectrum Health)	Transplant	Grand Rapids	MI	Heart	Heart	Adult	Programs of Excellence	PerformanceELITE	$391,840	30		72% of Billed Charges	80% of Billed Charges	70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	30% of Billed Charges	Begins at Evaluation	Begins One Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		42.9564627	-85.7301286	154.pdf
Corewell Health Grand Rapids Hospitals (Spectrum Health)	Transplant	Grand Rapids	MI	Lung	Lung	Adult	Programs of Excellence	PerformanceELITE	Lung Only: $310,039 \| Lung with ECMO: $603,432	Lung Only: 30 \| Lung with ECMO: 40		72% of Billed Charges	95% of Billed Charges	70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	30% of Billed Charges	Begins at Evaluation	Begins One Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		42.9564627	-85.7301286	155.pdf
Corewell Health Grand Rapids Hospitals (Spectrum Health)	Transplant	Grand Rapids	MI	Lung	Lung	Adult	Government Rates		Professional: 120% of Medicare Allowable \| All Other Services: 107% of Medicare Allowable					Professional: 120% of Medicare Allowable \| All Other Services: 107% of Medicare Allowable			Reimbursed Based on Most Current Available Medicare Cost Report Worksheet D-4 Using the Following Calculation: Total Cost Minus Revenue for Organ Sold Divided by Total Usable Organs	Reimbursed at Invoice Cost		Begins at Evaluation	Begins One Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		42.9564627	-85.7301286	156.pdf
Corewell Health Grand Rapids Hospitals (Spectrum Health)	Transplant	Grand Rapids	MI	Heart	Heart	Adult	Government Rates		Professional: 120% of Medicare Allowable \| All Other Services: 107% of Medicare Allowable					Professional: 120% of Medicare Allowable \| All Other Services: 107% of Medicare Allowable			Reimbursed Based on Most Current Available Medicare Cost Report Worksheet D-4 Using the Following Calculation: Total Cost Minus Revenue for Organ Sold Divided by Total Usable Organs			Begins at Evaluation	Begins One Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		42.9564627	-85.7301286	157.pdf
Corewell Health Grand Rapids Hospitals (Spectrum Health)	Transplant	Grand Rapids	MI	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates		Professional: 120% of Medicare Allowable \| All Other Services: 107% of Medicare Allowable					Professional: 120% of Medicare Allowable \| All Other Services: 107% of Medicare Allowable		Reimbursed at 107% of Medicare Allowable				Begins at Evaluation	Begins on the Day of Preparative Regimen and Ending the Day of Discharge	Ends 365 Days from Discharge		42.9564627	-85.7301286	158.pdf
Corewell Health Grand Rapids Hospitals (Spectrum Health)	Transplant	Grand Rapids	MI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates		Professional: 120% of Medicare Allowable \| All Other Services: 107% of Medicare Allowable					Professional: 120% of Medicare Allowable \| All Other Services: 107% of Medicare Allowable		Reimbursed at 107% of Medicare Allowable				Begins at Evaluation	Begins on the Day of Preparative Regimen and Ending the Day of Discharge	Ends 365 Days from Discharge		42.9564627	-85.7301286	158.pdf
Corewell Health Grand Rapids Hospitals (Spectrum Health)	Transplant	Grand Rapids	MI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Government Rates		Professional: 120% of Medicare Allowable \| All Other Services: 107% of Medicare Allowable					Professional: 120% of Medicare Allowable \| All Other Services: 107% of Medicare Allowable		Reimbursed at 107% of Medicare Allowable				Begins at Evaluation	Begins on the Day of Preparative Regimen and Ending the Day of Discharge	Ends 365 Days from Discharge		42.9564627	-85.7301286	158.pdf
Corewell Health Grand Rapids Hospitals (Spectrum Health)	Transplant	Grand Rapids	MI	Blood/Marrow (Autologous)	Autologous	Pediatric	Government Rates		Professional: 120% of Medicare Allowable \| All Other Services: 107% of Medicare Allowable					Professional: 120% of Medicare Allowable \| All Other Services: 107% of Medicare Allowable		Reimbursed at 107% of Medicare Allowable				Begins at Evaluation	Begins on the Day of Preparative Regimen and Ending the Day of Discharge	Ends 365 Days from Discharge		42.9564627	-85.7301286	158.pdf
Corewell Health Grand Rapids Hospitals (Spectrum Health)	Transplant	Grand Rapids	MI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Government Rates		Professional: 120% of Medicare Allowable \| All Other Services: 107% of Medicare Allowable					Professional: 120% of Medicare Allowable \| All Other Services: 107% of Medicare Allowable		Reimbursed at 107% of Medicare Allowable				Begins at Evaluation	Begins on the Day of Preparative Regimen and Ending the Day of Discharge	Ends 365 Days from Discharge		42.9564627	-85.7301286	158.pdf
Corewell Health Grand Rapids Hospitals (Spectrum Health)	Transplant	Grand Rapids	MI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Government Rates		Professional: 120% of Medicare Allowable \| All Other Services: 107% of Medicare Allowable					Professional: 120% of Medicare Allowable \| All Other Services: 107% of Medicare Allowable		Reimbursed at 107% of Medicare Allowable				Begins at Evaluation	Begins on the Day of Preparative Regimen and Ending the Day of Discharge	Ends 365 Days from Discharge		42.9564627	-85.7301286	158.pdf
Corewell Health William Beaumont University Hospital	Transplant	Royal Oak	MI	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$107,161	N/A			70% of Billed Charges	70% of Billed Charges			Included in Case Rate		If Charges Exceed $234,090, Payment will be the Case Rate, Plus 70% of the Excess Charges	Begins at Evaluation	Begins one day Prior to Admission and Ends at Discharge	Begins at Discharge and Ends 365 later		42.5073024	-83.1925775	159.pdf
Corewell Health William Beaumont University Hospital	Transplant	Royal Oak	MI	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	$211,201	N/A			70% of Billed Charges	70% of Billed Charges			Included in Case Rate		If Charges Exceed $468,180, Payment will be the Case Rate, Plus 70% of the Excess Charges	Begins at Evaluation	Begins one day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 365 later		42.5073024	-83.1925775	160.pdf
Corewell Health William Beaumont University Hospital	Transplant	Royal Oak	MI	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		$252,817	N/A			70% of Billed Charges	70% of Billed Charges			Included in Case Rate		If Charges Exceed $624,240, Payment will be the Case Rate, Plus 70% of the Excess Charges	Begins at Evaluation	Begins one day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 365 later		42.9564627	-85.7301286	161.pdf
Dana-Farber Cancer Institute	Transplant	Boston	MA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceELITE	Hospital: $125,000 \| Professional: 80% of Billed Charges	40		$2,260 Med/Surg \| $2,920 ICU/CCU	90% of Billed Charges for hospital	80% of Billed Charges	Included in Case Rate	80% of Billed Charges			65% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		42.3144556	-71.0403236	162.pdf
Dana-Farber Cancer Institute	Transplant	Boston	MA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceELITE	Hospital: $155,000 \| Professional: 80% of Billed Charges	45		$2,260 Med/Surg \| $2,920 ICU/CCU	90% of Billed Charges for hospital	80% of Billed Charges	Included in Case Rate	80% of Billed Charges			65% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		42.3144556	-71.0403236	162.pdf
Dana-Farber Cancer Institute	Transplant	Boston	MA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceELITE	Hospital: $100,000 \| Professional: 80% of Billed Charges	30		$2,260 Med/Surg \| $2,920 ICU/CCU	90% of Billed Charges for hospital	80% of Billed Charges	Included in Case Rate	80% of Billed Charges			65% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		42.3144556	-71.0403236	162.pdf
Duke University Hospital	Transplant	Durham	NC	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	$155,000	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges			Included in Case Rate	70% of Billed Charges	If Billed Charges Exceed $263,500, Payment will be the Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		36.0020232	-79.0249944	163.pdf
Duke University Hospital	Transplant	Durham	NC	Lung	Lung	Pediatric	Member's Choice		Single: $260,000 \| Bilateral: $270,000	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges			Included in Case Rate	70% of Billed Charges	If Billed Charges Exceed $450,500 (Single) or $459,000 (Bilateral), Payment will be the Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		36.0020232	-79.0249944	164.pdf
Duke University Hospital	Transplant	Durham	NC	Heart	Heart	Pediatric	Programs of Excellence		$240,000	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges			Included in Case Rate	70% of Billed Charges	If Billed Charges Exceed $408,000, Payment will be the Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		36.0020232	-79.0249944	165.pdf
Duke University Hospital	Transplant	Durham	NC	Kidney	Kidney	Pediatric	Member's Choice		Cadaveric Donor: $98,000 \| Living Donor: $105,000	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges			Included in Case Rate	70% of Billed Charges	If Billed Charges Exceed $178,500 (Cadaveric) or $166,600 (Living), Payment will be the Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		36.0020232	-79.0249944	166.pdf
Duke University Hospital	Transplant	Durham	NC	Liver	Liver	Pediatric	Programs of Excellence		Cadaveric Donor: $180,000 \| Living Donor: $190,000	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges			Included in Case Rate	70% of Billed Charges	If Billed Charges Exceed $306,000, Payment will be the Transplant Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		36.0020232	-79.0249944	167.pdf
Duke University Hospital	Transplant	Durham	NC	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$225,000	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges	Reimbursed Pursuant to the Transplant Phase in which the Services are Provided	Reimbursed Pursuant to the Transplant Phase in which the Services are Provided		70% of Billed Charges	If Billed Charges Exceed $382,500, Payment will be the Transplant Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins on the day of Preparatory Regimen and ends Upon Discharge	Ends One (1) Year from Discharge		36.0020232	-79.0249944	168.pdf
Duke University Hospital	Transplant	Durham	NC	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$270,000	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges	Reimbursed Pursuant to the Transplant Phase in which the Services are Provided	Reimbursed Pursuant to the Transplant Phase in which the Services are Provided		70% of Billed Charges	If Billed Charges Exceed $459,000, Payment will be the Transplant Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins on the day of Preparatory Regimen and ends Upon Discharge	Ends One (1) Year from Discharge		36.0020232	-79.0249944	168.pdf
Duke University Hospital	Transplant	Durham	NC	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$165,000	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges	Reimbursed Pursuant to the Transplant Phase in which the Services are Provided	Reimbursed Pursuant to the Transplant Phase in which the Services are Provided		70% of Billed Charges	If Billed Charges Exceed $280,500, Payment will be the Transplant Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins on the day of Preparatory Regimen and ends Upon Discharge	Ends One (1) Year from Discharge		36.0020232	-79.0249944	168.pdf
Duke University Hospital	Transplant	Durham	NC	Blood/Marrow (Cord Blood)	Cord Blood	Pediatric	Programs of Excellence		$310,000	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges	Reimbursed Pursuant to the Transplant Phase in which the Services are Provided	Reimbursed Pursuant to the Transplant Phase in which the Services are Provided		70% of Billed Charges	If Billed Charges Exceed $527,000, Payment will be the Transplant Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins on the day of Preparatory Regimen and ends Upon Discharge	Ends One (1) Year from Discharge		36.0020232	-79.0249944	168.pdf
Duke University Hospital	Transplant	Durham	NC	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Pediatric	Programs of Excellence		Paid at the Applicable Transplant Rate	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges	Reimbursed Pursuant to the Transplant Phase in which the Services are Provided	Reimbursed Pursuant to the Transplant Phase in which the Services are Provided		70% of Billed Charges	If Billed Charges Exceed the Applicable Threshold for Transplant Type, Payment will be the Transplant Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins on the day of Preparatory Regimen and ends Upon Discharge	Ends One (1) Year from Discharge		36.0020232	-79.0249944	168.pdf
Duke University Hospital	Transplant	Durham	NC	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Pediatric	Programs of Excellence		Paid at the Applicable Transplant Rate	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges	Reimbursed Pursuant to the Transplant Phase in which the Services are Provided	Reimbursed Pursuant to the Transplant Phase in which the Services are Provided		70% of Billed Charges	If Billed Charges Exceed the Applicable Threshold for Transplant Type, Payment will be the Transplant Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins on the day of Preparatory Regimen and ends Upon Discharge	Ends One (1) Year from Discharge		36.0020232	-79.0249944	168.pdf
Duke University Hospital	Transplant	Durham	NC	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$200,000	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed $340,000, Payment will be the Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins on the Day of Preparatory Regimen and Ends when the Patient is Discharged	Ends 365 Days from Discharge		36.0020232	-79.0249944	169.pdf
Duke University Hospital	Transplant	Durham	NC	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$248,000	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed $421,600, Payment will be the Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins on the Day of Preparatory Regimen and Ends when the Patient is Discharged	Ends 365 Days from Discharge		36.0020232	-79.0249944	169.pdf
Duke University Hospital	Transplant	Durham	NC	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$100,000	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges	Included in Case Rate	N/A			If Billed Charges Exceed $170,000, Payment will be the Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins on the Day of Preparatory Regimen and Ends when the Patient is Discharged	Ends 365 Days from Discharge		36.0020232	-79.0249944	169.pdf
Duke University Hospital	Transplant	Durham	NC	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceQUALITY	Paid at the Applicable Transplant Rate	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges	Reimbursed Pursuant to the Transplant Phase in which the Services are Provided	Reimbursed Pursuant to the Transplant Phase in which the Services are Provided		70% of Billed Charges	If Billed Charges Exceed the Applicable Threshold for Transplant Type, Payment will be the Transplant Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins on the day of Preparatory Regimen and ends Upon Discharge	Ends One (1) Year from Discharge		36.0020232	-79.0249944	169.pdf
Duke University Hospital	Transplant	Durham	NC	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Adult	Programs of Excellence	PerformanceQUALITY	Paid at the Applicable Transplant Rate	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges	Reimbursed Pursuant to the Transplant Phase in which the Services are Provided	Reimbursed Pursuant to the Transplant Phase in which the Services are Provided		70% of Billed Charges	If Billed Charges Exceed the Applicable Threshold for Transplant Type, Payment will be the Transplant Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins on the day of Preparatory Regimen and ends Upon Discharge	Ends One (1) Year from Discharge		36.0020232	-79.0249944	169.pdf
Duke University Hospital	Transplant	Durham	NC	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$220,000	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges			Included in Case Rate	70% of Billed Charges	If Billed Charges Exceed $374,000, Payment will be the Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		36.0020232	-79.0249944	170.pdf
Duke University Hospital	Transplant	Durham	NC	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor: $98,000 \| Living Donor: $105,000	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges			Included in Case Rate	70% of Billed Charges	If Billed Charges Exceed $178,500 (Cadaveric) or $166,600 (Living), Payment will be the Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		36.0020232	-79.0249944	171.pdf
Duke University Hospital	Transplant	Durham	NC	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor: $180,000 \| Living Donor: $190,000	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges			Included in Case Rate	70% of Billed Charges	If Billed Charges Exceed $323,000 (Cadaveric or Living), Payment will be the Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		36.0020232	-79.0249944	172.pdf
Duke University Hospital	Transplant	Durham	NC	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	Single: $250,000 \| Bilateral: $265,000	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges			Included in Case Rate	70% of Billed Charges	If Billed Charges Exceed $425,000 (Single) or $442,000 (Bilateral), Payment will be the Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		36.0020232	-79.0249944	173.pdf
Duke University Hospital	Transplant	Durham	NC	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Programs of Excellence	PerformanceQUALITY	$270,000	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges	Reimbursed Pursuant to the Transplant Phase in Which the Services are Provided	Reimbursed Pursuant to the Transplant Phase in Which the Services are Provided			If Billed Charges Exceed $421,600, Payment will be the Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins on the Day of Preparatory Regimen and Ends when the Patient is Discharged	Ends One (1) Year from Discharge		36.0020232	-79.0249944	174.pdf
Duke University Hospital	Transplant	Durham	NC	Pancreas	Pancreas	Adult	Programs of Excellence		$115,000	N/A		N/A	If Billed Charges are less than the Case Rate Payment Shall Be 90% of Billed Charges	72% of Billed Charges			Included in Case Rate	70% of Billed Charges	If Billed Charges Exceed $195,500, Payment will be the Case Rate, Plus 73% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		36.0020232	-79.0249944	175.pdf
Duke University Hospital	Transplant	Durham	NC	Multi-Organ	Multi-Organ	Adult	Member's Choice		80% of Billed Charges	N/A		N/A	N/A	80% of Billed Charges			Included in Case Rate	70% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		36.0020232	-79.0249944	176.pdf
Duke University Hospital	Transplant	Durham	NC	Multi-Organ	Multi-Organ	Pediatric	Member's Choice		80% of Billed Charges	N/A		N/A	N/A	80% of Billed Charges			Included in Case Rate	70% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		36.0020232	-79.0249944	176.pdf
Fred Hutchinson Cancer Center (Seattle Cancer Care Alliance)	Transplant	Seattle	WA	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$311,703	25		N/A	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Reimbursed at 80% of Billed Charges			75% of Billed Charges	First Day of Outpatient Work-up	Begins on the Day of Ablative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year After the Inlier Days have Elapsed		47.613007	-122.4122753	177.pdf
Fred Hutchinson Cancer Center (Seattle Cancer Care Alliance)	Transplant	Seattle	WA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		Matched: $477,942 \| Mismatched: $535,089	40		N/A	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Reimbursed at 80% of Billed Charges			75% of Billed Charges	First Day of Outpatient Work-up	Begins on the Day of Ablative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year After the Inlier Days have Elapsed		47.613007	-122.4122753	177.pdf
Fred Hutchinson Cancer Center (Seattle Cancer Care Alliance)	Transplant	Seattle	WA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$652,843	40		N/A	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Reimbursed at 80% of Billed Charges			75% of Billed Charges	First Day of Outpatient Work-up	Begins on the Day of Ablative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year After the Inlier Days have Elapsed		47.613007	-122.4122753	177.pdf
Fred Hutchinson Cancer Center (Seattle Cancer Care Alliance)	Transplant	Seattle	WA	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Pediatric	Programs of Excellence		80% of Billed Charges	N/A		N/A	N/A	80% of Billed Charges	Included in Case Rate	Reimbursed at 80% of Billed Charges			N/A	First Day of Outpatient Work-up	Begins on the Day of Ablative Therapy and ends when Patients is Discharged	Ends One (1) Year After Discharge		47.613007	-122.4122753	177.pdf
Fred Hutchinson Cancer Center (Seattle Cancer Care Alliance)	Transplant	Seattle	WA	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Pediatric	Programs of Excellence		80% of Billed Charges	N/A		N/A	N/A	80% of Billed Charges	Included in Case Rate	Reimbursed at 80% of Billed Charges			N/A	First Day of Outpatient Work-up	Begins on the Day of Ablative Therapy and ends when Patients is Discharged	Ends One (1) Year After Discharge		47.613007	-122.4122753	177.pdf
Fred Hutchinson Cancer Center (Seattle Cancer Care Alliance)	Transplant	Seattle	WA	Blood/Marrow (Cord Blood)	Cord Blood	Pediatric	Programs of Excellence		$606,594	40		N/A	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Reimbursed at 80% of Billed Charges			75% of Billed Charges	First Day of Outpatient Work-up	Begins on the Day of Ablative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year After the Inlier Days have Elapsed		47.613007	-122.4122753	177.pdf
Fred Hutchinson Cancer Center (Seattle Cancer Care Alliance)	Transplant	Seattle	WA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceELITE	$280,531	25		N/A	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Reimbursed at 80% of Billed Charges			70% of Billed Charges	First Day of Outpatient Work-up	Begins on the Day of Ablative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year After the Inlier Days have Elapsed		47.613007	-122.4122753	177.pdf
Fred Hutchinson Cancer Center (Seattle Cancer Care Alliance)	Transplant	Seattle	WA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceELITE	Matched: $424,261 \| Mismatched: $488,333	40		N/A	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Reimbursed at 80% of Billed Charges			70% of Billed Charges	First Day of Outpatient Work-up	Begins on the Day of Ablative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year After the Inlier Days have Elapsed		47.613007	-122.4122753	177.pdf
Fred Hutchinson Cancer Center (Seattle Cancer Care Alliance)	Transplant	Seattle	WA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceELITE	$593,965	40		N/A	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Reimbursed at 80% of Billed Charges			70% of Billed Charges	First Day of Outpatient Work-up	Begins on the Day of Ablative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year After the Inlier Days have Elapsed		47.613007	-122.4122753	177.pdf
Fred Hutchinson Cancer Center (Seattle Cancer Care Alliance)	Transplant	Seattle	WA	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceELITE	80% of Billed Charges	N/A		N/A	N/A	80% of Billed Charges	Included in Case Rate	Reimbursed at 80% of Billed Charges			N/A	First Day of Outpatient Work-up	Begins on the Day of Ablative Therapy and ends when Patients is Discharged	Ends One (1) Year After Discharge		47.613007	-122.4122753	177.pdf
Fred Hutchinson Cancer Center (Seattle Cancer Care Alliance)	Transplant	Seattle	WA	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Adult	Programs of Excellence	PerformanceELITE	80% of Billed Charges	N/A		N/A	N/A	80% of Billed Charges	Included in Case Rate	Reimbursed at 80% of Billed Charges			N/A	First Day of Outpatient Work-up	Begins on the Day of Ablative Therapy and ends when Patients is Discharged	Ends One (1) Year After Discharge		47.613007	-122.4122753	177.pdf
Fred Hutchinson Cancer Center (Seattle Cancer Care Alliance)	Transplant	Seattle	WA	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Programs of Excellence	PerformanceELITE	$546,618	40		N/A	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Reimbursed at 80% of Billed Charges			70% of Billed Charges	First Day of Outpatient Work-up	Begins on the Day of Ablative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year After the Inlier Days have Elapsed		47.613007	-122.4122753	177.pdf
Fred Hutchinson Cancer Center (Seattle Cancer Care Alliance)	Cellular Immunotherapy	Seattle	WA	Cellular Immunotherapy	Cellular Immunotherapy				Charges $0 - $500,000 Pay at 80% \| Charges $500,001 - $1,000,000 75% \| Charges $1,000,001 and Above Pay at 70% \| Drug Cost: 110% of Invoice Cost	N/A		N/A	N/A	80% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	178.pdf
Fred Hutchinson Cancer Center (Seattle Cancer Care Alliance)	Cancer	Seattle	WA	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															47.613007	-122.4122753	179.pdf
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	$160,000	20		$3,200	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost, Plus 10%	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and Applicable Outlier Days have Expired	Ends One (1) Year Post-Transplant		43.0578056	-88.1078546	884.pdf
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$125,000	20		$3,200	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost, Plus 10%	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and Applicable Outlier Days have Expired	Ends One (1) Year Post-Transplant		43.0578056	-88.1078546	180.pdf
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	$85,000	17		$1,500 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost, Plus 10%	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and Applicable Outlier Days have Expired	Ends One (1) Year Post-Transplant		43.0578056	-88.1078546	181.pdf
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	$140,000	20		$1,600 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost, Plus 10%	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and Applicable Outlier Days have Expired	Ends One (1) Year Post-Transplant		43.0578056	-88.1078546	182.pdf
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Pancreas	Pancreas	Adult	Programs of Excellence		$55,000	17		$1,500 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost, Plus 10%	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and Applicable Outlier Days have Expired	Ends One (1) Year Post-Transplant		43.0578056	-88.1078546	183.pdf
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	$85,000	25		$1,900 Med/Surg \| $2,800 ICU/CCU	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year Post-Transplant		43.0578056	-88.1078546	184.pdf
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	$127,000	30		$1,900 Med/Surg \| $2,800 ICU/CCU	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year Post-Transplant		43.0578056	-88.1078546	184.pdf
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	$150,000	30		$1,900 Med/Surg \| $2,800 ICU/CCU	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year Post-Transplant		43.0578056	-88.1078546	184.pdf
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceSELECT	1st Autologous BMT/PSCT: $85,000 \| 2nd Autologous BMT/PSCT: $85,000	1st Autologous BMT/PSCT: 25 \| 2nd Autologous BMT/PSCT: 25		$1,900 Med/Surg \| $2,800 ICU/CCU	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year Post-Transplant		43.0578056	-88.1078546	184.pdf
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Adult	Programs of Excellence	PerformanceSELECT	1st Autologous BMT/PSCT: $85,000 \| 2nd Allogeneic BMT/PSCT (Related Donor): $127,000 \| 3rd Allogeneic BMT/PSCT (Unrelated Donor): $150,000	1st Autologous BMT/PSCT: 25 \| 2nd Allogeneic BMT/PSCT (Related Donor): 30 \| 3rd Allogeneic BMT/PSCT (Unrelated Donor): 30		$1,900 Med/Surg \| $2,800 ICU/CCU	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year Post-Transplant		43.0578056	-88.1078546	184.pdf
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor: $59,422 \| Living Donor: $64,924	17		$1,651 Med/Surg \| $1,981 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost, Plus 10%	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and Applicable Outlier Days have Expired	Ends One (1) Year Post-Transplant		43.0578056	-88.1078546	185.pdf
Froedtert Memorial Lutheran Hospital	Cellular Immunotherapy	Milwaukee	WI	Cellular Immunotherapy	Cellular Immunotherapy				Charges $0 - $500,000 Pay at 65% \| Charges $500,001 - $1,000,000 Pay at 60% \| Charges $1,000,001 and Above Pay at 55% \| Drug Cost: 100% of Invoice Cost	N/A		N/A	N/A	65% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends One (1) Year from Discharge		43.0578056	-88.1078546	186.pdf
Froedtert Memorial Lutheran Hospital	Destination VAD	Milwaukee	WI	Destination VAD	Destination VAD				Surgical Event: 70% of Billed Charges	N/A		N/A	90% of Billed Charges	70% of Billed Charges				50% of Billed Charges	$570,000 & 65% of Billed Charges Thereafter	Begins at Evaluation	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		43.0578056	-88.1078546	187.pdf
Froedtert Memorial Lutheran Hospital	Bariatric	Milwaukee	WI	Bariatric	Bariatric				Gastric Banding: $40,856 \| Gastric Bypass: $43,280 \| Gastric Sleeve: $27,836	Gastric Banding: 2 \| Gastric Bypass: 3 \| Gastric Sleeve: 2		$4,489		70% of Billed Charges					N/A	Begins at Evaluation	Begins on the Day of Surgery and Ends when the Number of Inlier Days and Applicable Outlier Days have Expired	Begins at Discharge and Ends One (1) Year Later		43.0578056	-88.1078546	188.pdf
Henry Ford Hospital	Transplant	Detroit	MI	Intestine	Intestine	Adult	Programs of Excellence		70% of Billed Charges	N/A		N/A	N/A	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		42.3528165	-83.1692446	189.pdf
Henry Ford Hospital	Transplant	Detroit	MI	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$276,329	N/A		N/A	85% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Billed Charges Exceed $552,659, Payment will be the Transplant Case Rate, Plus 48% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		42.3528165	-83.1692446	190.pdf
Henry Ford Hospital	Transplant	Detroit	MI	Pancreas	Pancreas	Adult	Member's Choice		$211,311	N/A		N/A	85% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Billed Charges Exceed $422,622, Payment will be the Transplant Case Rate, Plus 48% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		42.3528165	-83.1692446	191.pdf
Henry Ford Hospital	Transplant	Detroit	MI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$195,056	N/A		N/A	85% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed $390,112, Payment will be the Transplant Case Rate, Plus 48% of the Excess Charges	Begins at Evaluation	Begins On the Day of Admission For Preparative Therapy and Ends at Discharge	Ends 365 Days from Discharge		42.3528165	-83.1692446	192.pdf
Henry Ford Hospital	Transplant	Detroit	MI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$227,565	N/A		N/A	85% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed $455,131, Payment will be the Transplant Case Rate, Plus 48% of the Excess Charges	Begins at Evaluation	Begins On the Day of Admission For Preparative Therapy and Ends at Discharge	Ends 365 Days from Discharge		42.3528165	-83.1692446	192.pdf
Henry Ford Hospital	Transplant	Detroit	MI	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$130,037	N/A		N/A	85% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed $260,075, Payment will be the Transplant Case Rate, Plus 48% of the Excess Charges	Begins at Evaluation	Begins On the Day of Admission For Preparative Therapy and Ends at Discharge	Ends 365 Days from Discharge		42.3528165	-83.1692446	192.pdf
Henry Ford Hospital	Transplant	Detroit	MI	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$273,079	N/A		N/A	85% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Billed Charges Exceed $514,731, Payment will be the Transplant Case Rate, Plus 48% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		42.3528165	-83.1692446	193.pdf
Henry Ford Hospital	Transplant	Detroit	MI	Kidney	Kidney	Adult	Member's Choice		$157,129	N/A		N/A	85% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Billed Charges Exceed $314,257, Payment will be the Transplant Case Rate, Plus 48% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		42.3528165	-83.1692446	194.pdf
Henry Ford Hospital	Transplant	Detroit	MI	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	$243,820	N/A		N/A	85% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Billed Charges Exceed $487,640, Payment will be the Transplant Case Rate, Plus 48% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		42.3528165	-83.1692446	195.pdf
Henry Ford Hospital	Transplant	Detroit	MI	Lung	Lung	Adult	Member's Choice		$270,911	N/A		N/A	85% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Billed Charges Exceed $509,313, Payment will be the Transplant Case Rate, Plus 48% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		42.3528165	-83.1692446	196.pdf
Henry Ford Hospital	Transplant	Detroit	MI	Multi-Visceral	Multi-Visceral	Adult	Member's Choice		70% of Billed Charges	N/A		N/A	N/A	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		42.3528165	-83.1692446	189.pdf
Henry Ford Hospital	Transplant	Detroit	MI	Multi-Organ	Multi-Organ	Adult	Member's Choice		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	N/A		N/A	85% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Billed Charges Exceed Higher Organ Threshold, Plus 50% of Lower Organ Threshold, Payment will be the Transplant Case Rate, Plus 48% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		42.3528165	-83.1692446	198.pdf
Henry Ford Hospital	Destination VAD	Detroit	MI	Destination VAD	Destination VAD				70% of Billed Charges	N/A		N/A	N/A	70% of Billed Charges				Reimbursed at 55% of Billed Charges	N/A	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		42.3526896	-83.1694159	193.pdf
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Heart/Lung	Heart/Lung	Adult	Member's Choice		Hospital: $612,838 \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	30		$5,348 ICU/CCU \| $4,160 Med/Surg	100% of Billed Charges	Hospital Inpatient: Lesser of 100% of Billed Charges or applicable per diems \| Hospital Outpatient: 67% of Billed Charges \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area			Included in Case Rate	Reimbursed at Invoice Cost	40% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant and Ends at Discharge	Ends One (1) Year from Discharge		40.0024768	-75.1882393	200.pdf
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Pancreas	Pancreas	Adult	Programs of Excellence		Hospital: $179,137 \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	20		$5,348 ICU/CCU \| $4,160 Med/Surg	100% of Billed Charges	Hospital Inpatient: Lesser of 100% of Billed Charges or applicable per diems \| Hospital Outpatient: 67% of Billed Charges \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area			Included in Case Rate	Reimbursed at Invoice Cost	40% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant and Ends at Discharge	Ends One (1) Year from Discharge		40.0024768	-75.1882393	201.pdf
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $179,136 \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	30		$5,348 ICU/CCU \| $4,160 Med/Surg	100% of Billed Charges	Hospital Inpatient: Lesser of 100% of Billed Charges or applicable per diems \| Hospital Outpatient: 67% of Billed Charges \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	Reimbursed at the Pre-Transplant Rate	N/A			40% of Billed Charges	Begins at Evaluation	Begins on the Day of Mobilization and Ends at Discharge	Ends One (1) Year from Discharge		40.0024768	-75.1882393	202.pdf
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $311,132 \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	35		$5,348 ICU/CCU \| $4,160 Med/Surg	100% of Billed Charges	Hospital Inpatient: Lesser of 100% of Billed Charges or applicable per diems \| Hospital Outpatient: 67% of Billed Charges \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	Reimbursed at the Pre-Transplant Rate	N/A			40% of Billed Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		40.0024768	-75.1882393	202.pdf
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $311,132 \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	40		$5,348 ICU/CCU \| $4,160 Med/Surg	100% of Billed Charges	Hospital Inpatient: Lesser of 100% of Billed Charges or applicable per diems \| Hospital Outpatient: 67% of Billed Charges \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	Reimbursed at the Pre-Transplant Rate	N/A			40% of Billed Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		40.0024768	-75.1882393	202.pdf
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $558,154 \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	25		$5,348 ICU/CCU \| $4,160 Med/Surg	100% of Billed Charges	Hospital Inpatient: Lesser of 100% of Billed Charges or applicable per diems \| Hospital Outpatient: 67% of Billed Charges \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area			Included in Case Rate	Reimbursed at Invoice Cost	40% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant and Ends at Discharge	Ends One (1) Year from Discharge		40.0024768	-75.1882393	203.pdf
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	Hospital: $188,566 \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	20		$5,348 ICU/CCU \| $4,160 Med/Surg	100% of Billed Charges	Hospital Inpatient: Lesser of 100% of Billed Charges or applicable per diems \| Hospital Outpatient: 67% of Billed Charges \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area			Included in Case Rate	Reimbursed at Invoice Cost	40% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant and Ends at Discharge	Ends One (1) Year from Discharge		40.0024768	-75.1882393	204.pdf
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceELITE	Hospital: $245,135 \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	20		$5,348 ICU/CCU \| $4,160 Med/Surg	100% of Billed Charges	Hospital Inpatient: Lesser of 100% of Billed Charges or applicable per diems \| Hospital Outpatient: 67% of Billed Charges \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area			Included in Case Rate	Reimbursed at Invoice Cost	40% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant and Ends at Discharge	Ends One (1) Year from Discharge		40.0024768	-75.1882393	205.pdf
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $339,419 \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	35		$5,348 ICU/CCU \| $4,160 Med/Surg	100% of Billed Charges	Hospital Inpatient: Lesser of 100% of Billed Charges or applicable per diems \| Hospital Outpatient: 67% of Billed Charges \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area			Included in Case Rate	Reimbursed at Invoice Cost	40% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant and Ends at Discharge	Ends One (1) Year from Discharge		40.0024768	-75.1882393	206.pdf
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	Bilateral Lung Hospital: $443,128 \| Bilateral Lung Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area \| Single Lung Hospital: $414,845 \| Single Lung Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	35		$5,348 ICU/CCU \| $4,160 Med/Surg	100% of Billed Charges	Hospital Inpatient: Lesser of 100% of Billed Charges or applicable per diems \| Hospital Outpatient: 67% of Billed Charges \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area			Included in Case Rate	Reimbursed at Invoice Cost	40% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant and Ends at Discharge	Ends One (1) Year from Discharge		40.0024768	-75.1882393	207.pdf
Houston Methodist Hospital	Transplant	Houston	TX	Heart/Lung	Heart/Lung	Adult	Member's Choice		Hospital: 60% of Billed Charges \| Professional: 70% of Billed Charges	N/A			90% of Billed Charges	75% of Billed Charges			Included in Case Rate	55% of Hospital Billed Charges	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.8171037	-95.5417172	208.pdf
Houston Methodist Hospital	Transplant	Houston	TX	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		Hospital: 60% of Billed Charges \| Professional: 70% of Billed Charges	N/A			90% of Billed Charges	75% of Billed Charges			Included in Case Rate	55% of Hospital Billed Charges	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.8171037	-95.5417172	209.pdf
Houston Methodist Hospital	Transplant	Houston	TX	Pancreas	Pancreas	Adult	Programs of Excellence		Hospital: 60% of Billed Charges \| Professional: 70% of Billed Charges	N/A			90% of Billed Charges	75% of Billed Charges			Included in Case Rate	55% of Hospital Billed Charges	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.8171037	-95.5417172	210.pdf
Houston Methodist Hospital	Transplant	Houston	TX	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $80,000 \| Professional: $20,000	20		$750 Med/Surg \| $1,000 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	N/A		55% of Hospital Billed Charges	55% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.8171037	-95.5417172	211.pdf
Houston Methodist Hospital	Transplant	Houston	TX	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $125,000 \| Professional: $40,000	30		$750 Med/Surg \| $1,000 ICU/CCU	90% of Billed Charges	75% of Billed Charges	100% of Invoice Cost	100% of Invoice Cost		55% of Hospital Billed Charges	55% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.8171037	-95.5417172	211.pdf
Houston Methodist Hospital	Transplant	Houston	TX	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $100,000 \| Professional: $36,000	25		$750 Med/Surg \| $1,000 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	100% of Invoice Cost		55% of Hospital Billed Charges	55% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.8171037	-95.5417172	211.pdf
Houston Methodist Hospital	Transplant	Houston	TX	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $110,000 \| Professional: $36,500	20		$750 Med/Surg \| $1,000 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	55% of Hospital Billed Charges	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.8171037	-95.5417172	212.pdf
Houston Methodist Hospital	Transplant	Houston	TX	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $58,000 \| Professional: $23,400	15		$500 Med/Surg \| $750 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	55% of Hospital Billed Charges	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.8171037	-95.5417172	213.pdf
Houston Methodist Hospital	Transplant	Houston	TX	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: 60% of Billed Charges \| Professional: 70% of Billed Charges	N/A			90% of Billed Charges	75% of Billed Charges			Included in Case Rate	55% of Hospital Billed Charges	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.8171037	-95.5417172	214.pdf
Houston Methodist Hospital	Transplant	Houston	TX	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $90,000 \| Professional: $38,000	15		$500 Med/Surg \| $750 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	55% of Hospital Billed Charges	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.8171037	-95.5417172	215.pdf
Houston Methodist Hospital	Transplant	Houston	TX	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $125,000 \| Professional: $48,900	20		$500 Med/Surg \| $750 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	55% of Hospital Billed Charges	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.8171037	-95.5417172	216.pdf
Indiana Blood & Marrow Transplantation	Transplant	Indianapolis	IN	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$110,000	35		$2,000 Med/Surg \| $2,500 ICU/Ccu	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.7799642	-86.2728331	217.pdf
Indiana Blood & Marrow Transplantation	Transplant	Indianapolis	IN	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$140,000	40		$2,000 Med/Surg \| $2,500 ICU/Ccu	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.7799642	-86.2728331	217.pdf
Indiana Blood & Marrow Transplantation	Transplant	Indianapolis	IN	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$80,000	30		$2,000 Med/Surg \| $2,500 ICU/Ccu	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.7799642	-86.2728331	217.pdf
Indiana University Health	Cellular Immunotherapy	Indianapolis	IN	Cellular Immunotherapy	Cellular Immunotherapy				$267,664 \| Drug Cost: 100% of Invoice Cost	N/A		N/A	80% of Billed Charges	65% of Billed Charges					If Charges Exceed $547,494, Payment will be the Case Rate, Plus 59% of the Excess Charges	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends One (1) Year from Discharge		39.7796999	-86.2731749	218.pdf
Indiana University Health	Transplant	Indianapolis	IN	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$200,748	35		$4,501 Med/Surg/ICU/CCU	80% of Billed Charges	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges	Included in Case Rate	N/A			Charges that Exceed the Stop Loss Threshold Amount ($547,494) Shall be Reimbursed at 59%	Begins at Evaluation	Begins on the Day Prior to Ablative Therapy and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	219.pdf
Indiana University Health	Transplant	Indianapolis	IN	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$261,581	40		$4,501 Med/Surg/ICU/CCU	80% of Billed Charges	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges	Included in Case Rate	N/A			Charges that Exceed the Stop Loss Threshold Amount ($596,159) Shall be Reimbursed at 59%	Begins at Evaluation	Begins on the Day Prior to Ablative Therapy and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	219.pdf
Indiana University Health	Transplant	Indianapolis	IN	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$154,515	20		$4,501 Med/Surg/ICU/CCU	80% of Billed Charges	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges	Included in Case Rate	N/A			Charges that Exceed the Stop Loss Threshold Amount ($309,030) Shall be Reimbursed at 59%	Begins at Evaluation	Begins on the Day Prior to Ablative Therapy and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	219.pdf
Indiana University Health	Transplant	Indianapolis	IN	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Member's Choice		1st: $148,431 \| 2nd: $121,664	20 \| 20		$4,501 Med/Surg/ICU/CCU	80% of Billed Charges	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges	Included in Case Rate	N/A			Charges that Exceed the Stop Loss Threshold Amount (1st: $296,863; 2nd: $243,331) Shall be Reimbursed at 59%	Begins at Evaluation	Begins on the Day Prior to Ablative Therapy and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	219.pdf
Indiana University Health	Transplant	Indianapolis	IN	Kidney	Kidney	Adult	Member's Choice		$119,232	12		$4,501 Med/Surg/ICU/CCU	80% of Billed Charges	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges			Included in Case Rate	120% of Invoice Cost if During the Transplant Inpatient Admission. If Implanted During Pre or Post Transplant Phase, Reimburse at that Provision Rate	Charges that Exceed the Stop Loss Threshold Amount ($238,465) Shall be Reimbursed at 59%	Begins at Evaluation	Begins on the Day Prior to Transplant and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	220.pdf
Indiana University Health	Transplant	Indianapolis	IN	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		$395,412	25		$4,501 Med/Surg/ICU/CCU	80% of Billed Charges	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges			Included in Case Rate	120% of Invoice Cost if During the Transplant Inpatient Admission. If Implanted During Pre or Post Transplant Phase, Reimburse at that Provision Rate	Charges that Exceed the Stop Loss Threshold Amount ($912,490) Shall be Reimbursed at 59%	Begins at Evaluation	Begins on the Day Prior to Transplant and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	221.pdf
Indiana University Health	Transplant	Indianapolis	IN	Pancreas	Pancreas	Adult	Member's Choice		$155,732	15		$4,501 Med/Surg/ICU/CCU	80% of Billed Charges	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges			Included in Case Rate	120% of Invoice Cost if During the Transplant Inpatient Admission. If Implanted During Pre or Post Transplant Phase, Reimburse at that Provision Rate	Charges that Exceed the Stop Loss Threshold Amount ($311,464) Shall be Reimbursed at 59%	Begins at Evaluation	Begins on the Day Prior to Transplant and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	222.pdf
Indiana University Health	Transplant	Indianapolis	IN	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceELITE	$221,431	15		$4,501 Med/Surg/ICU/CCU	80% of Billed Charges	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges			Included in Case Rate	120% of Invoice Cost if During the Transplant Inpatient Admission. If Implanted During Pre or Post Transplant Phase, Reimburse at that Provision Rate	Charges that Exceed the Stop Loss Threshold Amount ($442,861) Shall be Reimbursed at 59%	Begins at Evaluation	Begins on the Day Prior to Transplant and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	223.pdf
Indiana University Health	Transplant	Indianapolis	IN	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	$273,747	23		$4,501 Med/Surg/ICU/CCU	80% of Billed Charges	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges			Included in Case Rate	120% of Invoice Cost if During the Transplant Inpatient Admission. If Implanted During Pre or Post Transplant Phase, Reimburse at that Provision Rate	Charges that Exceed the Stop Loss Threshold Amount ($547,494) Shall be Reimbursed at 59%	Begins at Evaluation	Begins on the Day Prior to Transplant and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	224.pdf
Indiana University Health	Transplant	Indianapolis	IN	Multi-Visceral	Multi-Visceral	Adult	Member's Choice		65% of Billed Charges	N/A		N/A	N/A	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges			Included in Case Rate	120% of Invoice Cost if During the Transplant Inpatient Admission. If Implanted During Pre or Post Transplant Phase, Reimburse at that Provision Rate	N/A	Begins at Evaluation	Begins on the Day Prior to Transplant and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	225.pdf
Indiana University Health	Transplant	Indianapolis	IN	Heart	Heart	Adult	Member's Choice		$267,664	22		$4,501 Med/Surg/ICU/CCU	80% of Billed Charges	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges			Included in Case Rate	120% of Invoice Cost if During the Transplant Inpatient Admission. If Implanted During Pre or Post Transplant Phase, Reimburse at that Provision Rate	Charges that Exceed the Stop Loss Threshold Amount ($656,993) Shall be Reimbursed at 59%	Begins at Evaluation	Begins on the Day Prior to Transplant and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	226.pdf
Indiana University Health	Transplant	Indianapolis	IN	Lung	Lung	Adult	Programs of Excellence	PerformanceELITE	Single: $176,414 \| Bilateral: $267,664	20 \| 25		$4,501 Med/Surg/ICU/CCU	80% of Billed Charges	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges			Included in Case Rate	120% of Invoice Cost if During the Transplant Inpatient Admission. If Implanted During Pre or Post Transplant Phase, Reimburse at that Provision Rate	Charges that Exceed the Stop Loss Threshold Amount (Single: $510,995; Double: $625,359) Shall be Reimbursed at 59%	Begins at Evaluation	Begins on the Day Prior to Transplant and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	227.pdf
Indiana University Health - Riley Hospital for Children	Transplant	Indianapolis	IN	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$218,998	35		$4,501 Med/Surg/ICU/CCU	80% of Billed Charges	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges	Included in Case Rate	N/A			Charges that Exceed the Stop Loss Threshold Amount ($577,909) Shall be Reimbursed at 59%	Begins at Evaluation	Begins on the Day Prior to Ablative Therapy and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	219.pdf
Indiana University Health - Riley Hospital for Children	Transplant	Indianapolis	IN	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$304,164	40		$4,501 Med/Surg/ICU/CCU	80% of Billed Charges	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges	Included in Case Rate	N/A			Charges that Exceed the Stop Loss Threshold Amount ($639,960) Shall be Reimbursed at 59%	Begins at Evaluation	Begins on the Day Prior to Ablative Therapy and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	219.pdf
Indiana University Health - Riley Hospital for Children	Transplant	Indianapolis	IN	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$201,965	20		$4,501 Med/Surg/ICU/CCU	80% of Billed Charges	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges	Included in Case Rate	N/A			Charges that Exceed the Stop Loss Threshold Amount ($403,929) Shall be Reimbursed at 59%	Begins at Evaluation	Begins on the Day Prior to Ablative Therapy and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	219.pdf
Indiana University Health - Riley Hospital for Children	Transplant	Indianapolis	IN	Kidney	Kidney	Pediatric	Programs of Excellence		$135,048	12		$4,501 Med/Surg/ICU/CCU	80% of Billed Charges	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges			Included in Case Rate	120% of Invoice Cost if During the Transplant Inpatient Admission. If Implanted During Pre or Post Transplant Phase, Reimburse at that Provision Rate	Charges that Exceed the Stop Loss Threshold Amount ($270,097) Shall be Reimbursed at 59%	Begins at Evaluation	Begins on the Day Prior to Transplant and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	220.pdf
Indiana University Health - Riley Hospital for Children	Transplant	Indianapolis	IN	Liver	Liver	Pediatric	Member's Choice		$334,580	23		$4,501 Med/Surg/ICU/CCU	80% of Billed Charges	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges			Included in Case Rate	120% of Invoice Cost if During the Transplant Inpatient Admission. If Implanted During Pre or Post Transplant Phase, Reimburse at that Provision Rate	Charges that Exceed the Stop Loss Threshold Amount ($669,159) Shall be Reimbursed at 59%	Begins at Evaluation	Begins on the Day Prior to Transplant and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	224.pdf
Indiana University Health - Riley Hospital for Children	Transplant	Indianapolis	IN	Multi-Visceral	Multi-Visceral	Pediatric	Member's Choice		65% of Billed Charges	N/A		N/A	N/A	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges			Included in Case Rate	120% of Invoice Cost if During the Transplant Inpatient Admission. If Implanted During Pre or Post Transplant Phase, Reimburse at that Provision Rate	N/A	Begins at Evaluation	Begins on the Day Prior to Transplant and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	225.pdf
Indiana University Health - Riley Hospital for Children	Transplant	Indianapolis	IN	Heart	Heart	Pediatric	Programs of Excellence		$285,914	22		$4,501 Med/Surg/ICU/CCU	80% of Billed Charges	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges			Included in Case Rate	120% of Invoice Cost if During the Transplant Inpatient Admission. If Implanted During Pre or Post Transplant Phase, Reimburse at that Provision Rate	Charges that Exceed the Stop Loss Threshold Amount ($705,659) Shall be Reimbursed at 59%	Begins at Evaluation	Begins on the Day Prior to Transplant and Ends at Discharge	Ends Ninety (90) Days Post Discharge		39.7799642	-86.2728331	226.pdf
Integris Baptist Medical Center	Transplant	Oklahoma City	OK	Heart	Heart	Adult	Member's Choice		$130,000	20		$2,500 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 75% of Billed Charges	If Billed Charges Exceed $260,000, Payment will be the Transplant Case Rate Plus 70% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at discharge	Ends One (1) Year Post-Transplant		35.4825666	-97.6196227	228.pdf
Integris Baptist Medical Center	Transplant	Oklahoma City	OK	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$58,500	12		$2,500 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 75% of Billed Charges	If Billed Charges Exceed $117,000, Payment will be the Transplant Case Rate Plus 70% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at discharge	Ends One (1) Year Post-Transplant		35.4825666	-97.6196227	229.pdf
Integris Baptist Medical Center	Transplant	Oklahoma City	OK	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	$115,000	15		$2,500 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 75% of Billed Charges	If Billed Charges Exceed $230,000, Payment will be the Transplant Case Rate Plus 70% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at discharge	Ends One (1) Year Post-Transplant		35.4825666	-97.6196227	230.pdf
Integris Baptist Medical Center	Transplant	Oklahoma City	OK	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	$144,500	20		$2,500 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 75% of Billed Charges	If Billed Charges Exceed $289,000, Payment will be the Transplant Case Rate Plus 70% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at discharge	Ends One (1) Year Post-Transplant		35.4825666	-97.6196227	231.pdf
Integris Baptist Medical Center	Transplant	Oklahoma City	OK	Lung	Lung	Adult	Member's Choice		Single: $130,000 \| Bilateral: $178,000	25		$2,500 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 75% of Billed Charges	If Billed Charges Exceed $260,000 (Single) or $356,000 (Bilateral), Payment will be the Transplant Case Rate Plus 70% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at discharge	Ends One (1) Year Post-Transplant		35.4825666	-97.6196227	232.pdf
Integris Baptist Medical Center	Transplant	Oklahoma City	OK	Pancreas	Pancreas	Adult	Programs of Excellence		$75,000	15		$2,500 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 75% of Billed Charges	If Billed Charges Exceed $150,000, Payment will be the Transplant Case Rate Plus 70% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at discharge	Ends One (1) Year Post-Transplant		35.4825666	-97.6196227	855.pdf
Integris Baptist Medical Center	Transplant	Oklahoma City	OK	Liver	Liver	Pediatric	Member's Choice		$144,500	20		$2,500 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 75% of Billed Charges	If Billed Charges Exceed $289,000, Payment will be the Transplant Case Rate Plus 70% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at discharge	Ends One (1) Year Post-Transplant		35.4825666	-97.6196227	856.pdf
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Heart/Lung	Heart/Lung	Adult	Member's Choice		Hospital: 65% of Billed Charges \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 75% of Billed Charges \| Professional: 80% of Billed Charges			Included in Case Rate	65% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	233.pdf
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Heart/Lung	Heart/Lung	Pediatric	Member's Choice		Hospital: 65% of Billed Charges \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 75% of Billed Charges \| Professional: 80% of Billed Charges			Included in Case Rate	65% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	233.pdf
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: 65% of Billed Charges \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 75% of Billed Charges \| Professional: 80% of Billed Charges			65% of Billed Charges	65% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	234.pdf
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Lung	Lung	Pediatric	Member's Choice		Hospital: 65% of Billed Charges \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 75% of Billed Charges \| Professional: 80% of Billed Charges			65% of Billed Charges	65% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	234.pdf
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Heart	Heart	Pediatric	Member's Choice		Hospital: $316,412 \| Professional: 80% of Billed Charges	35		Hospital: Lesser of 80% of Billed Charges or $2,150 Med/Surg; $2,875 ICU/CCU \| Professional: 80% of Billed Charges	80% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 80% of Billed Charges			Included in Case Rate	65% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	235.pdf
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Heart	Heart	Adult	Member's Choice		Hospital: $300,164 \| Professional: $103,711	17		Hospital: Lesser of 80% of Billed Charges or $2,150 Med/Surg; $2,875 ICU/CCU \| Professional: 80% of Billed Charges	80% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 80% of Billed Charges			Included in Case Rate	65% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	235.pdf
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Liver	Liver	Pediatric	Programs of Excellence		Hospital Cadaveric Donor: $316,412 \| Hospital Living Donor: $333,516 \| Professional Cadaveric or Living Donor: $101,825 \| Professional Living Donor Services: 80% of Billed Charges	22 \| 25 \| 14		Hospital: Lesser of 80% of Billed Charges or $2,150 Med/Surg; $2,875 ICU/CCU \| Professional: 80% of Billed Charges	80% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 80% of Billed Charges			Included in Case Rate	65% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	236.pdf
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Heart/Kidney	Heart/Kidney	Adult	Member's Choice		Hospital: $393,826 \| Professional: 80% of Billed Charges	12 \| 3		Hospital: Lesser of 80% of Billed Charges or $2,150 Med/Surg; $2,875 ICU/CCU \| Professional: 80% of Billed Charges	80% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 80% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	237.pdf
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Multi-Visceral	Multi-Visceral	Pediatric	Programs of Excellence		Hospital: 65% of Billed Charges \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 75% of Billed Charges \| Professional: 80% of Billed Charges			65% of Billed Charges	N/A	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	238.pdf
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Multi-Visceral	Multi-Visceral	Adult	Programs of Excellence		Hospital: 65% of Billed Charges \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 75% of Billed Charges \| Professional: 80% of Billed Charges			65% of Billed Charges	65% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	238.pdf
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $196,689 \| Professional: $41,861 \| Professional (Living Donor): $15,556	12 \| 3		Hospital: Lesser of 80% of Billed Charges or $2,150 Med/Surg; $2,875 ICU/CCU \| Professional: 80% of Billed Charges	80% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 80% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	239.pdf
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Kidney	Kidney	Pediatric	Programs of Excellence		Hospital: $196,689 \| Professional: $47,171 \| Professional (Living Donor): $15,556	12 \| 3		Hospital: Lesser of 80% of Billed Charges or $2,150 Med/Surg; $2,875 ICU/CCU \| Professional: 80% of Billed Charges	80% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 80% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	239.pdf
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $249,598 \| Professional: 80% of Billed Charges	15		Hospital: Lesser of 80% of Billed Charges or $2,150 Med/Surg; $2,875 ICU/CCU \| Professional: 80% of Billed Charges	80% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 80% of Billed Charges			Included in Case Rate	65% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	240.pdf
Jackson Memorial Hospital University of Miami School of Medicine	Congenital Heart Defect	Miami	FL	Congenital Heart Defect	Congenital Heart Defect				Hospital: 75% of Billed Charges \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 75% of Billed Charges \| Professional: 80% of Billed Charges				70% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7824033	-80.2645636	243.pdf
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Liver	Liver	Adult	Member's Choice		Hospital Cadaveric Donor: $316,412 \| Hospital Living Donor: $333,516 \| Professional Cadaveric or Living Donor: $93,717 \| Professional Living Donor Services: 80% of Billed Charges	22 \| 25 \| 14		Hospital: Lesser of 80% of Billed Charges or $2,150 Med/Surg; $2,875 ICU/CCU \| Professional: 80% of Billed Charges	80% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 80% of Billed Charges			Included in Case Rate	65% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	854.pdf
Jackson Memorial Hospital University of Miami School of Medicine (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	Miami	FL	Kidney	Kidney	Adult	Government Rates		Hospital: 120% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outlier Applicable to Services Provided \| Professional: $41,861 \| Professional Living Donor Services: $15,556	Hospital: N/A \| Professional: 12 (Patient) 3 (Donor)		Hospital: N/A \| Professional: 80% of Billed Charges	Hospital: N/A \| Professional: 80% of Billed Charges	Hospital: 105% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outliers Applicable to Services Provided. Codes not Listed on the Current Medicare Fee Schedule shall be Reimbursed at 60% of Billed Charges \| Professional: 80% of Billed Charges			Reimbursed in Accordance with the Medicare Cost Report (Commonly Referred to as the D-4 Report)	Hospital: 60% of Billed Charges \| Professional: 80% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	241.pdf
Jackson Memorial Hospital University of Miami School of Medicine (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	Miami	FL	Kidney	Kidney	Pediatric	Government Rates		Hospital: 120% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outlier Applicable to Services Provided \| Professional: $47,141 \| Professional Living Donor Services: $15,556	Hospital: N/A \| Professional: 12 (Patient) 3 (Donor)		Hospital: N/A \| Professional: 80% of Billed Charges	Hospital: N/A \| Professional: 80% of Billed Charges	Hospital: 105% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outliers Applicable to Services Provided. Codes not Listed on the Current Medicare Fee Schedule shall be Reimbursed at 60% of Billed Charges \| Professional: 80% of Billed Charges			Reimbursed in Accordance with the Medicare Cost Report (Commonly Referred to as the D-4 Report)	Hospital: 60% of Billed Charges \| Professional: 80% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	241.pdf
Jackson Memorial Hospital University of Miami School of Medicine (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	Miami	FL	Liver	Liver	Adult	Government Rates		Hospital: 120% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outlier Applicable to Services Provided \| Professional: $93,717 \| Professional Living Donor Services: 80% of Billed Charges	Hospital: N/A \| Professional: 14 (Cadaveric) 25 (Living)		Hospital: N/A \| Professional: 80% of Billed Charges	Hospital: N/A \| Professional: 80% of Billed Charges	105% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outliers Applicable to Services Provided. Codes not Listed on the Current Medicare Fee Schedule shall be Reimbursed at 60% of Billed Charges \| Professional: 80% of Billed Charges			Reimbursed in Accordance with the Medicare Cost Report (Commonly Referred to as the D-4 Report)	Hospital: 60% of Billed Charges \| Professional: 80% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	241.pdf
Jackson Memorial Hospital University of Miami School of Medicine (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	Miami	FL	Liver	Liver	Pediatric	Government Rates		Hospital: 120% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outlier Applicable to Services Provided \| Professional: $101,825 \| Professional Living Donor Services: 80% of Billed Charges	Hospital: N/A \| Professional: 30 (Cadaveric) 14 (Living)		Hospital: N/A \| Professional: 80% of Billed Charges	Hospital: N/A \| Professional: 80% of Billed Charges	105% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outliers Applicable to Services Provided. Codes not Listed on the Current Medicare Fee Schedule shall be Reimbursed at 60% of Billed Charges \| Professional: 80% of Billed Charges			Reimbursed in Accordance with the Medicare Cost Report (Commonly Referred to as the D-4 Report)	Hospital: 60% of Billed Charges \| Professional: 80% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	241.pdf
Jackson Memorial Hospital University of Miami School of Medicine (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	Miami	FL	Lung	Lung	Adult	Government Rates		Hospital: 120% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outlier Applicable to Services Provided \| Professional: 80% of Billed Charges	N/A		N/A	Hospital: N/A \| Professional: 80% of Billed Charges	105% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outliers Applicable to Services Provided. Codes not Listed on the Current Medicare Fee Schedule shall be Reimbursed at 60% of Billed Charges \| Professional: 80% of Billed Charges			Reimbursed in Accordance with the Medicare Cost Report (Commonly Referred to as the D-4 Report)	Hospital: 60% of Billed Charges \| Professional: 80% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	241.pdf
Jackson Memorial Hospital University of Miami School of Medicine (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	Miami	FL	Lung	Lung	Pediatric	Government Rates		Hospital: 120% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outlier Applicable to Services Provided \| Professional: 80% of Billed Charges	N/A		N/A	Hospital: N/A \| Professional: 80% of Billed Charges	105% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outliers Applicable to Services Provided. Codes not Listed on the Current Medicare Fee Schedule shall be Reimbursed at 60% of Billed Charges \| Professional: 80% of Billed Charges			Reimbursed in Accordance with the Medicare Cost Report (Commonly Referred to as the D-4 Report)	Hospital: 60% of Billed Charges \| Professional: 80% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	241.pdf
Jackson Memorial Hospital University of Miami School of Medicine (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	Miami	FL	Intestine	Intestine	Adult	Government Rates		Hospital: 120% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outlier Applicable to Services Provided \| Professional: 80% of Billed Charges	N/A		N/A	Hospital: N/A \| Professional: 80% of Billed Charges	105% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outliers Applicable to Services Provided. Codes not Listed on the Current Medicare Fee Schedule shall be Reimbursed at 60% of Billed Charges \| Professional: 80% of Billed Charges			Reimbursed in Accordance with the Medicare Cost Report (Commonly Referred to as the D-4 Report)	Hospital: 60% of Billed Charges \| Professional: 80% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	241.pdf
Jackson Memorial Hospital University of Miami School of Medicine (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	Miami	FL	Multi-Visceral	Multi-Visceral	Adult	Government Rates		Hospital: 120% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outlier Applicable to Services Provided \| Professional: 80% of Billed Charges	N/A		N/A	Hospital: N/A \| Professional: 80% of Billed Charges	105% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outliers Applicable to Services Provided. Codes not Listed on the Current Medicare Fee Schedule shall be Reimbursed at 60% of Billed Charges \| Professional: 80% of Billed Charges			Reimbursed in Accordance with the Medicare Cost Report (Commonly Referred to as the D-4 Report)	Hospital: 60% of Billed Charges \| Professional: 80% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	241.pdf
Jackson Memorial Hospital University of Miami School of Medicine (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	Miami	FL	Heart	Heart	Adult	Government Rates		Hospital: 120% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outlier Applicable to Services Provided \| Professional: $103,711	Hospital: N/A \| Professional: 17		Hospital: N/A \| Professional: 80% of Billed Charges	Hospital: N/A \| Professional: 80% of Billed Charges	105% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outliers Applicable to Services Provided. Codes not Listed on the Current Medicare Fee Schedule shall be Reimbursed at 60% of Billed Charges \| Professional: 80% of Billed Charges			Reimbursed in Accordance with the Medicare Cost Report (Commonly Referred to as the D-4 Report)	Hospital: 60% of Billed Charges \| Professional: 80% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	241.pdf
Jackson Memorial Hospital University of Miami School of Medicine (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	Miami	FL	Heart/Lung	Heart/Lung	Adult	Government Rates		Hospital: 120% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outlier Applicable to Services Provided \| Professional: 80% of Billed Charges	N/A		N/A	Hospital: N/A \| Professional: 80% of Billed Charges	105% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outliers Applicable to Services Provided. Codes not Listed on the Current Medicare Fee Schedule shall be Reimbursed at 60% of Billed Charges \| Professional: 80% of Billed Charges			Reimbursed in Accordance with the Medicare Cost Report (Commonly Referred to as the D-4 Report)	Hospital: 60% of Billed Charges \| Professional: 80% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	241.pdf
Jackson Memorial Hospital University of Miami School of Medicine (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	Miami	FL	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates		Hospital: 120% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outlier Applicable to Services Provided \| Professional: 80% of Billed Charges	N/A		N/A	Hospital: N/A \| Professional: 80% of Billed Charges	105% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outliers Applicable to Services Provided. Codes not Listed on the Current Medicare Fee Schedule shall be Reimbursed at 60% of Billed Charges \| Professional: 80% of Billed Charges			Reimbursed in Accordance with the Medicare Cost Report (Commonly Referred to as the D-4 Report)	Hospital: 60% of Billed Charges \| Professional: 80% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	241.pdf
Jackson Memorial Hospital University of Miami School of Medicine (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	Miami	FL	Multi-Organ	Multi-Organ	Adult	Government Rates		Hospital: 120% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outlier Applicable to Services Provided \| Professional: 80% of Billed Charges	N/A		N/A	Hospital: N/A \| Professional: 80% of Billed Charges	105% of Medicare Allowable Amounts Current on the Date Services were Rendered Including Outliers Applicable to Services Provided. Codes not Listed on the Current Medicare Fee Schedule shall be Reimbursed at 60% of Billed Charges \| Professional: 80% of Billed Charges			Reimbursed in Accordance with the Medicare Cost Report (Commonly Referred to as the D-4 Report)	Hospital: 60% of Billed Charges \| Professional: 80% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		25.7825453	-80.2994984	241.pdf
Johns Hopkins Hospital	Transplant	Baltimore	MD	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	Included in Case Rate	Hospital - HSCRC rates Professional - 80% of Billed Charges			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	250.pdf
Johns Hopkins Hospital	Transplant	Baltimore	MD	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	Included in Case Rate	Hospital - HSCRC rates Professional - 80% of Billed Charges			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	250.pdf
Johns Hopkins Hospital	Transplant	Baltimore	MD	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	Included in Case Rate	Hospital - HSCRC rates Professional - 80% of Billed Charges			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	250.pdf
Johns Hopkins Hospital	Transplant	Baltimore	MD	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceELITE	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	Included in Case Rate	Hospital: HSCRC Rates \| Professional: 80% of Billed Charges			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	250.pdf
Johns Hopkins Hospital	Transplant	Baltimore	MD	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceELITE	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	Included in Case Rate	Hospital: HSCRC Rates \| Professional: 80% of Billed Charges			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	250.pdf
Johns Hopkins Hospital	Transplant	Baltimore	MD	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceELITE	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	Included in Case Rate	Hospital: HSCRC Rates \| Professional: 80% of Billed Charges			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	250.pdf
Johns Hopkins Hospital	Transplant	Baltimore	MD	Pancreas	Pancreas	Adult	Programs of Excellence		Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges			Included in Case Rate	Reimbursed at HSCRC Rate	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	251.pdf
Johns Hopkins Hospital	Transplant	Baltimore	MD	Heart	Heart	Pediatric	Member's Choice		Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges			Included in Case Rate	Reimbursed at HSCRC Rate	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	251.pdf
Johns Hopkins Hospital	Transplant	Baltimore	MD	Kidney	Kidney	Pediatric	Programs of Excellence		Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges			Included in Case Rate	Reimbursed at HSCRC Rate	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	251.pdf
Johns Hopkins Hospital	Transplant	Baltimore	MD	Liver	Liver	Pediatric	Member's Choice		Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges			Included in Case Rate	Reimbursed at HSCRC Rate	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	251.pdf
Johns Hopkins Hospital	Transplant	Baltimore	MD	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges			Included in Case Rate	Reimbursed at HSCRC Rate	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	251.pdf
Johns Hopkins Hospital	Transplant	Baltimore	MD	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges			Included in Case Rate	Reimbursed at HSCRC Rate	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	251.pdf
Johns Hopkins Hospital	Transplant	Baltimore	MD	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges			Included in Case Rate	Reimbursed at HSCRC Rate	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	251.pdf
Johns Hopkins Hospital	Transplant	Baltimore	MD	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges			Included in Case Rate	Reimbursed at HSCRC Rate	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	251.pdf
Johns Hopkins Hospital	Transplant	Baltimore	MD	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Rates \| Professional: 80% of Billed Charges			Included in Case Rate	Reimbursed at HSCRC Rate	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	251.pdf
Johns Hopkins Hospital	Cellular Immunotherapy	Baltimore	MD	Cellular Immunotherapy	Cellular Immunotherapy				100% of the State of Maryland HSCRC rates \| Drug Cost: 100% of the State of Maryland HSCRC rates \| For all other Services not regulated by the HSCRC \| Hospital: 60% of Billed Charges \| Professional: 80% of Billed Charges	N/A		N/A	N/A	100% of the State of Maryland HSCRC rates \| Professional: 80% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends 365 Days from Discharge		39.2846853	-76.6907077	252.pdf
Johns Hopkins Hospital (Applies to Medicaid Patients in the State of MD and Medicare Advantage Patients)	Transplant	Baltimore	MD	Kidney	Kidney	Adult	Government Rates		Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges				N/A	Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges			100% of HSCRC Rates Less Applicable discount for Medicare Advantage or Maryland Medicaid MCOs; Provided, However, in the Event that the HSCRC Determines that Kidney Organ Acquisition for Medicare Advantage Members will be Reimbursed by the Centers for Medicare and Medicaid Services (CMS) under the Original Medicare Fee-for-Service Program as Provided under the 21st Century Cures Act and other Applicable Statutes and Regulations, this Provision shall Automatically be Deemed to be Amended to Reflect this Alternate Reimbursement.	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs	N/A	Begins at Notification	Begins One Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1 Year Later		39.2848183	-76.6905365	253.pdf
Johns Hopkins Hospital (Applies to Medicaid Patients in the State of MD and Medicare Advantage Patients)	Transplant	Baltimore	MD	Liver	Liver	Adult	Government Rates		Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges				N/A	Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges			100% of HSCRC Rates Less Applicable discount for Medicare Advantage or Maryland Medicaid MCOs.	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs	N/A	Begins at Notification	Begins One Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1 Year Later		39.2848183	-76.6905365	253.pdf
Johns Hopkins Hospital (Applies to Medicaid Patients in the State of MD and Medicare Advantage Patients)	Transplant	Baltimore	MD	Pancreas	Pancreas	Adult	Government Rates		Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges				N/A	Hosptial: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges			100% of HSCRC Rates Less Applicable discount for Medicare Advantage or Maryland Medicaid MCOs.	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs	N/A	Begins at Notification	Begins One Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1 Year Later		39.2848183	-76.6905365	253.pdf
Johns Hopkins Hospital (Applies to Medicaid Patients in the State of MD and Medicare Advantage Patients)	Transplant	Baltimore	MD	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates		Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges				N/A	Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges			100% of HSCRC Rates Less Applicable discount for Medicare Advantage or Maryland Medicaid MCOs; Provided, However, in the Event that the HSCRC Determines that Kidney Organ Acquisition for Medicare Advantage Members will be Reimbursed by the Centers for Medicare and Medicaid Services (CMS) under the Original Medicare Fee-for-Service Program as Provided under the 21st Century Cures Act and other Applicable Statutes and Regulations, this Provision shall Automatically be Deemed to be Amended to Reflect this Alternate Reimbursement.	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs	N/A	Begins at Notification	Begins One Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1 Year Later		39.2848183	-76.6905365	253.pdf
Johns Hopkins Hospital (Applies to Medicaid Patients in the State of MD and Medicare Advantage Patients)	Transplant	Baltimore	MD	Heart	Heart	Adult	Government Rates		Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges				N/A	Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges			100% of HSCRC Rates Less Applicable discount for Medicare Advantage or Maryland Medicaid MCOs.	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs	N/A	Begins at Notification	Begins One Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1 Year Later		39.2848183	-76.6905365	253.pdf
Johns Hopkins Hospital (Applies to Medicaid Patients in the State of MD and Medicare Advantage Patients)	Transplant	Baltimore	MD	Lung	Lung	Adult	Government Rates		Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges				N/A	Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges			100% of HSCRC Rates Less Applicable discount for Medicare Advantage or Maryland Medicaid MCOs.	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs	N/A	Begins at Notification	Begins One Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1 Year Later		39.2848183	-76.6905365	253.pdf
Johns Hopkins Hospital (Applies to Medicaid Patients in the State of MD and Medicare Advantage Patients)	Transplant	Baltimore	MD	Kidney	Kidney	Pediatric	Government Rates		Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges				N/A	Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges			100% of HSCRC Rates Less Applicable discount for Medicare Advantage or Maryland Medicaid MCOs; Provided, However, in the Event that the HSCRC Determines that Kidney Organ Acquisition for Medicare Advantage Members will be Reimbursed by the Centers for Medicare and Medicaid Services (CMS) under the Original Medicare Fee-for-Service Program as Provided under the 21st Century Cures Act and other Applicable Statutes and Regulations, this Provision shall Automatically be Deemed to be Amended to Reflect this Alternate Reimbursement.	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs	N/A	Begins at Notification	Begins One Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1 Year Later		39.2848183	-76.6905365	253.pdf
Johns Hopkins Hospital (Applies to Medicaid Patients in the State of MD and Medicare Advantage Patients)	Transplant	Baltimore	MD	Liver	Liver	Pediatric	Government Rates		Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges				N/A	Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges			100% of HSCRC Rates Less Applicable discount for Medicare Advantage or Maryland Medicaid MCOs.	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs	N/A	Begins at Notification	Begins One Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1 Year Later		39.2848183	-76.6905365	253.pdf
Johns Hopkins Hospital (Applies to Medicaid Patients in the State of MD and Medicare Advantage Patients)	Transplant	Baltimore	MD	Pancreas	Pancreas	Pediatric	Government Rates		Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges				N/A	Hosptial: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges			100% of HSCRC Rates Less Applicable discount for Medicare Advantage or Maryland Medicaid MCOs.	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs	N/A	Begins at Notification	Begins One Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1 Year Later		39.2848183	-76.6905365	253.pdf
Johns Hopkins Hospital (Applies to Medicaid Patients in the State of MD and Medicare Advantage Patients)	Transplant	Baltimore	MD	Kidney/Pancreas	Kidney/Pancreas	Pediatric	Government Rates		Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges				N/A	Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges			100% of HSCRC Rates Less Applicable discount for Medicare Advantage or Maryland Medicaid MCOs; Provided, However, in the Event that the HSCRC Determines that Kidney Organ Acquisition for Medicare Advantage Members will be Reimbursed by the Centers for Medicare and Medicaid Services (CMS) under the Original Medicare Fee-for-Service Program as Provided under the 21st Century Cures Act and other Applicable Statutes and Regulations, this Provision shall Automatically be Deemed to be Amended to Reflect this Alternate Reimbursement.	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs	N/A	Begins at Notification	Begins One Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1 Year Later		39.2848183	-76.6905365	253.pdf
Johns Hopkins Hospital (Applies to Medicaid Patients in the State of MD and Medicare Advantage Patients)	Transplant	Baltimore	MD	Heart	Heart	Pediatric	Government Rates		Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges				N/A	Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges			100% of HSCRC Rates Less Applicable discount for Medicare Advantage or Maryland Medicaid MCOs.	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs	N/A	Begins at Notification	Begins One Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1 Year Later		39.2848183	-76.6905365	253.pdf
Johns Hopkins Hospital (Applies to Medicaid Patients in the State of MD and Medicare Advantage Patients)	Transplant	Baltimore	MD	Lung	Lung	Pediatric	Government Rates		Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges				N/A	Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges			100% of HSCRC Rates Less Applicable discount for Medicare Advantage or Maryland Medicaid MCOs.	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs	N/A	Begins at Notification	Begins One Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1 Year Later		39.2848183	-76.6905365	253.pdf
Johns Hopkins Hospital (Applies to Medicaid Patients in the State of MD and Medicare Advantage Patients)	Transplant	Baltimore	MD	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates		Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges		N/A		N/A	Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs			N/A	Begins at Notification	Begins on the First Day of Preparative Regimen and Ends Sixty Days Later	Begins at Discharge and Ends 1 Year Later		39.2848183	-76.6905365	254.pdf
Johns Hopkins Hospital (Applies to Medicaid Patients in the State of MD and Medicare Advantage Patients)	Transplant	Baltimore	MD	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates		Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges		N/A		N/A	Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs			N/A	Begins at Notification	Begins on the First Day of Preparative Regimen and Ends Sixty Days Later	Begins at Discharge and Ends 1 Year Later		39.2848183	-76.6905365	254.pdf
Johns Hopkins Hospital (Applies to Medicaid Patients in the State of MD and Medicare Advantage Patients)	Transplant	Baltimore	MD	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Related	Adult	Government Rates		Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges		N/A		N/A	Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs			N/A	Begins at Notification	Begins on the First Day of Preparative Regimen and Ends Sixty Days Later	Begins at Discharge and Ends 1 Year Later		39.2848183	-76.6905365	254.pdf
Johns Hopkins Hospital (Applies to Medicaid Patients in the State of MD and Medicare Advantage Patients)	Transplant	Baltimore	MD	Blood/Marrow (Autologous)	Autologous	Pediatric	Government Rates		Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges		N/A		N/A	Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs			N/A	Begins at Notification	Begins on the First Day of Preparative Regimen and Ends Sixty Days Later	Begins at Discharge and Ends 1 Year Later		39.2848183	-76.6905365	254.pdf
Johns Hopkins Hospital (Applies to Medicaid Patients in the State of MD and Medicare Advantage Patients)	Transplant	Baltimore	MD	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Government Rates		Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges		N/A		N/A	Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs			N/A	Begins at Notification	Begins on the First Day of Preparative Regimen and Ends Sixty Days Later	Begins at Discharge and Ends 1 Year Later		39.2848183	-76.6905365	254.pdf
Johns Hopkins Hospital (Applies to Medicaid Patients in the State of MD and Medicare Advantage Patients)	Transplant	Baltimore	MD	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Related	Pediatric	Government Rates		Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges		N/A		N/A	Hospital: 100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs \| Professional: 80% of Billed Charges	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs	100% of HSCRC Rates Less Applicable Discount for Medicare Advantage or Maryland Medicaid MCOs			N/A	Begins at Notification	Begins on the First Day of Preparative Regimen and Ends Sixty Days Later	Begins at Discharge and Ends 1 Year Later		39.2848183	-76.6905365	254.pdf
Karmanos Cancer Center	Transplant	Detroit	MI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$130,000	45		$1,800 Non-ICU \| $2,400 ICU	85% of Billed Charges	Hospital: 70% of Billed Charges \| Professional: 80% of Billed Charges	Included in Case Rate	70% of Billed Charges			Billed Charges Exceed the Outlier Threshold of $260,000, Payment will be the Transplant Case Rate, Plus 60% of the Charges Beyond the Outlier Threshold Amount	Begins at Evaluation	Begins on the First Day of Transplant Admission and Ends when the Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		42.3528165	-83.1692446	255.pdf
Karmanos Cancer Center	Transplant	Detroit	MI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$155,000	45		$1,800 Non-ICU \| $2,400 ICU	85% of Billed Charges	Hospital: 70% of Billed Charges \| Professional: 80% of Billed Charges	Included in Case Rate	70% of Billed Charges			Billed Charges Exceed the Outlier Threshold of $310,000, Payment will be the Transplant Case Rate, Plus 60% of the Charges Beyond the Outlier Threshold Amount	Begins at Evaluation	Begins on the First Day of Transplant Admission and Ends when the Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		42.3528165	-83.1692446	255.pdf
Karmanos Cancer Center	Transplant	Detroit	MI	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$85,000	30		$1,800 Non-ICU \| $2,400 ICU	85% of Billed Charges	Hospital: 70% of Billed Charges \| Professional: 80% of Billed Charges	Included in Case Rate	70% of Billed Charges			If Billed Charges Exceed the Outlier Threshold of $170,000, Payment will be the Transplant Case Rate, Plus 60% of the Charges Beyond the Outlier Threshold Amount	Begins at Evaluation	Begins on the First Day of Transplant Admission and Ends when the Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		42.3528165	-83.1692446	255.pdf
Keck Hospital of USC	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceELITE	$201,250	30	In its entirety from First Day of Ablative Therapy Through the Day of last Infusion Occurs Completely on an Outpatient basis	45% of Billed Charges	90% of Billed Charges	45% of Billed Charges	45% of Billed Charges	45% of Billed Charges			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		34.053691	-118.242766	256.pdf
Keck Hospital of USC	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceELITE	$247,250	35	In its entirety from First Day of Ablative Therapy Through the Day of last Infusion Occurs Completely on an Outpatient basis	45% of Billed Charges	90% of Billed Charges	45% of Billed Charges	45% of Billed Charges	45% of Billed Charges			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		34.053691	-118.242766	256.pdf
Keck Hospital of USC	Transplant	Los Angeles	CA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceELITE	$120,750	25	In its entirety from First Day of Ablative Therapy Through the Day of last Infusion Occurs Completely on an Outpatient basis	45% of Billed Charges	90% of Billed Charges	45% of Billed Charges	45% of Billed Charges	45% of Billed Charges			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		34.053691	-118.242766	256.pdf
Keck Hospital of USC	Transplant	Los Angeles	CA	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceELITE	1st Transplant: 120,750 \| 2nd Transplant: 97,750	30	In its entirety from First Day of Ablative Therapy Through the Day of last Infusion Occurs Completely on an Outpatient basis	45% of Billed Charges	90% of Billed Charges	45% of Billed Charges	Reinbursed at Invoice Cost	45% of Billed Charges			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		34.053691	-118.242766	256.pdf
Keck Hospital of USC	Transplant	Los Angeles	CA	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$106,950	18		45% of Billed Charges	90% of Billed Charges	45% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends 365 Days from Discharge		34.053691	-118.242766	257.pdf
Keck Hospital of USC	Transplant	Los Angeles	CA	Heart/Lung	Heart/Lung	Adult	Member's Choice		$189,750	28		45% of Billed Charges	90% of Billed Charges	45% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends 365 Days from Discharge		34.053691	-118.242766	258.pdf
Keck Hospital of USC	Transplant	Los Angeles	CA	Kidney	Kidney	Adult	Member's Choice		Cadeveric Donor: $86,250 \| Living Donor: $74,750 \| Donor Services: $32,200	12		45% of Billed Charges	90% of Billed Charges	45% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends 365 Days from Discharge		34.053691	-118.242766	259.pdf
Keck Hospital of USC	Transplant	Los Angeles	CA	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$111,550	18		45% of Billed Charges	90% of Billed Charges	45% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends 365 Days from Discharge		34.053691	-118.242766	260.pdf
Keck Hospital of USC	Transplant	Los Angeles	CA	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	Cadeveric Donor: $169,050 \| Living Donor: $161,000 \| Donor Services: $32,200	24		45% of Billed Charges	90% of Billed Charges	45% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends 365 Days from Discharge		34.053691	-118.242766	261.pdf
Keck Hospital of USC	Transplant	Los Angeles	CA	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	Cadeveric Donor Single: $148,350 \| Cadeveric Donor Bilateral: $184,000 \| Living Donor Single: $166,750 \| Living Donor Bilateral: $157,550 \| Donor Services: $31,000	21 \| Donor Services: 12		N/A	90% of Billed Charges	45% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends 365 Days from Discharge		34.053691	-118.242766	262.pdf
Keck Hospital of USC	Transplant	Los Angeles	CA	Multi-Organ	Multi-Organ	Adult	Member's Choice		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	Equal to Number of Days of Higher Cost Organ		45% of Billed Charges	90% of Billed Charges	45% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends 365 Days from Discharge		34.053691	-118.242766	263.pdf
Keck Hospital of USC	Transplant	Los Angeles	CA	Pancreas	Pancreas	Adult	Member's Choice		$97,750	18		45% of Billed Charges	90% of Billed Charges	45% of Billed Charges			Reimbursed at Invoice Cost		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		34.053691	-118.242766	264.pdf
Keck Hospital of USC	Transplant	Los Angeles	CA	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		$169,050 \| Kidney Donor Services: $32,200 \| Liver Donor Services: $32,200	28		45% of Billed Charges	90% of Billed Charges	45% of Billed Charges			Reimbursed at Invoice Cost		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		34.053691	-118.242766	265.pdf
Keck Hospital of USC (Applies to Medicare Advantage Only)	Transplant	Los Angeles	CA	Heart	Heart	Adult	Government Rates		Hospital: 125% of Medicare Fee Schedule \| Professional: 125% of Medicare Fee Schedule	N/A		N/A	N/A	Hospital: 125% of Medicare Fee Schedule \| Professional: 125% of Medicare Fee Schedule			$65,000 (Includes Transportation Costs)	100% of Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		34.053691	-118.242766	266.pdf
Keck Hospital of USC (Applies to Medicare Advantage Only)	Transplant	Los Angeles	CA	Heart/Lung	Heart/Lung	Adult	Government Rates		Hospital: 125% of Medicare Fee Schedule \| Professional: 125% of Medicare Fee Schedule	N/A		N/A	N/A	Hospital: 125% of Medicare Fee Schedule \| Professional: 125% of Medicare Fee Schedule			$65,000 (Includes Transportation Costs)	100% of Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		34.053691	-118.242766	267.pdf
Keck Hospital of USC (Applies to Medicare Advantage Only)	Transplant	Los Angeles	CA	Kidney	Kidney	Adult	Government Rates		Hospital: 125% of Medicare Fee Schedule \| Professional: 125% of Medicare Fee Schedule	N/A		N/A	N/A	Hospital: 125% of Medicare Fee Schedule \| Professional: 125% of Medicare Fee Schedule			$65,000 (Includes Transportation Costs)	100% of Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		34.053691	-118.242766	268.pdf
Keck Hospital of USC (Applies to Medicare Advantage Only)	Transplant	Los Angeles	CA	Kidney/Liver	Kidney/Liver	Adult	Government Rates		Hospital: 125% of Medicare Fee Schedule \| Professional: 125% of Medicare Fee Schedule	N/A		N/A	N/A	Hospital: 125% of Medicare Fee Schedule \| Professional: 125% of Medicare Fee Schedule			$65,000 (Includes Transportation Costs)	100% of Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		34.053691	-118.242766	269.pdf
Keck Hospital of USC (Applies to Medicare Advantage Only)	Transplant	Los Angeles	CA	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates		Hospital: 125% of Medicare Fee Schedule \| Professional: 125% of Medicare Fee Schedule	N/A		N/A	N/A	Hospital: 125% of Medicare Fee Schedule \| Professional: 125% of Medicare Fee Schedule			$65,000 (Includes Transportation Costs)	100% of Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		34.053691	-118.242766	270.pdf
Keck Hospital of USC (Applies to Medicare Advantage Only)	Transplant	Los Angeles	CA	Liver	Liver	Adult	Government Rates		Hospital: 125% of Medicare Fee Schedule \| Professional: 125% of Medicare Fee Schedule	N/A		N/A	N/A	Hospital: 125% of Medicare Fee Schedule \| Professional: 125% of Medicare Fee Schedule			$65,000 (Includes Transportation Costs)	100% of Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		34.053691	-118.242766	271.pdf
Keck Hospital of USC (Applies to Medicare Advantage Only)	Transplant	Los Angeles	CA	Lung	Lung	Adult	Government Rates		Hospital: 125% of Medicare Fee Schedule \| Professional: 125% of Medicare Fee Schedule	N/A		N/A	N/A	Hospital: 125% of Medicare Fee Schedule \| Professional: 125% of Medicare Fee Schedule			$65,000 (Includes Transportation Costs)	100% of Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		34.053691	-118.242766	272.pdf
Keck Hospital of USC (Applies to Medicare Advantage Only)	Transplant	Los Angeles	CA	Pancreas	Pancreas	Adult	Government Rates		Hospital: 125% of Medicare Fee Schedule \| Professional: 125% of Medicare Fee Schedule	N/A		N/A	N/A	Hospital: 125% of Medicare Fee Schedule \| Professional: 125% of Medicare Fee Schedule			$65,000 (Includes Transportation Costs)	100% of Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		34.053691	-118.242766	273.pdf
Lahey Clinic Medical Center	Transplant	Burlington	MA	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$100,000	30		70% of Billed Charges	95% of Billed Charges	70% of Billed Charges	Included in Case Rate	N/A			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		42.5051924	-71.23983	274.pdf
Lahey Clinic Medical Center	Transplant	Burlington	MA	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		$205,000	25		70% of Billed Charges	95% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		42.5051924	-71.23983	275.pdf
Lahey Clinic Medical Center	Transplant	Burlington	MA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric: $75,000 \| Living: $70,000	12		70% of Billed Charges	95% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		42.5051924	-71.23983	276.pdf
Lahey Clinic Medical Center	Transplant	Burlington	MA	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric: $170,000 \| Living: $180,000	20		70% of Billed Charges	95% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		42.5051924	-71.23983	277.pdf
Lucile Salter Packard Children's Hospital at Stanford	Transplant	Palo Alto	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$217,000	N/A	N/A	N/A	70% of Billed Charges	60% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Any Charges that Exceed $450,000 Shall be Reimbursed at 50% of Billed Charges, in Addition to the Case Rate	Begins at Evaluation	Begins on the Day of Admission for Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		37.425713	-122.1703694	278.pdf
Lucile Salter Packard Children's Hospital at Stanford	Transplant	Palo Alto	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$238,000	N/A	N/A	N/A	70% of Billed Charges	60% of Billed Charges	Reimbursed at Invoice Cost	Reimbursed at Invoice Cost			Any Charges that Exceed $500,000 Shall be Reimbursed at 50% of Billed Charges, in Addition to the Case Rate	Begins at Evaluation	Begins on the Day of Admission for Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		37.425713	-122.1703694	278.pdf
Lucile Salter Packard Children's Hospital at Stanford	Transplant	Palo Alto	CA	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$152,000	N/A	N/A	N/A	70% of Billed Charges	60% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Any Charges that Exceed $320,000 Shall be Reimbursed at 50% of Billed Charges, in Addition to the Case Rate	Begins at Evaluation	Begins on the Day of Admission for Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		37.425713	-122.1703694	278.pdf
Lucile Salter Packard Children's Hospital at Stanford	Transplant	Palo Alto	CA	Heart	Heart	Pediatric	Programs of Excellence		$280,000	N/A		N/A	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	Any Charges that Exceed $575,000 Shall be Reimbursed at 50% of Billed Charges, in Addition to the Case Rate	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		37.425713	-122.1703694	279.pdf
Lucile Salter Packard Children's Hospital at Stanford	Transplant	Palo Alto	CA	Heart/Lung	Heart/Lung	Pediatric	Member's Choice		$450,000	N/A		N/A	70% of Billed Charges	60% of Billed Charges			First Organ: Included in Case Rate \| Second and any Additional Organs: Paid at invoice Cost	Reimbursed at Invoice Cost	Any Charges that Exceed $937,500 Shall be Reimbursed at 50% of Billed Charges, in Addition to the Case Rate	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		37.425713	-122.1703694	280.pdf
Lucile Salter Packard Children's Hospital at Stanford	Transplant	Palo Alto	CA	Kidney	Kidney	Pediatric	Programs of Excellence		Cadeveric Donor: $145,000 \| Living Donor: $130,000	N/A		N/A	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	Any Charges that Exceed $300,000 (Cadaveric) or $270,000 (Living) Shall be Reimbursed at 50% of Billed Charges, in Addition to the Case Rate	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		37.425713	-122.1703694	281.pdf
Lucile Salter Packard Children's Hospital at Stanford	Transplant	Palo Alto	CA	Liver	Liver	Pediatric	Programs of Excellence		Cadeveric Donor: $238,000 \| Living Donor: $264,000	N/A		N/A	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	Any Charges that Exceed $500,000 (Cadaveric) or $535,000 (Living) Shall be Reimbursed at 50% of Billed Charges, in Addition to the Case Rate	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		37.425713	-122.1703694	282.pdf
Lucile Salter Packard Children's Hospital at Stanford	Transplant	Palo Alto	CA	Lung	Lung	Pediatric	Programs of Excellence		Single or Bilateral: 310,000	N/A		N/A	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	Any Charges that Exceed $650,000 Shall be Reimbursed at 50% of Billed Charges, in Addition to the Case Rate	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		37.425713	-122.1703694	283.pdf
Lucile Salter Packard Children's Hospital at Stanford	Transplant	Palo Alto	CA	Multi-Organ	Multi-Organ	Pediatric	Member's Choice		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	N/A		N/A	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	Charges that Exceed the Associated Organ Threshold Shall be Reimbursed at 50% of Billed Charges, in Addition to the Case Rate	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		37.425713	-122.1703694	284.pdf
Lucile Salter Packard Children's Hospital at Stanford	Cellular Immunotherapy	Palo Alto	CA	Cellular Immunotherapy	Cellular Immunotherapy				Charges $0 - $500,000 Pay at 60% \| Charges $500,001 - $1,000,000 Pay at 50% \| Charges $1,000,001 and Above Pay at 40% \| Drug Cost: 110% of Wholesale Acquisition Cost (WAC)	N/A		N/A	N/A	60% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends One (1) Year from Discharge		37.4256448	-122.1704551	285.pdf
Massachusetts General Hospital	Transplant	Boston	MA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceELITE	Hospital: $125,000 \| Professional: 80% of Billed Charges	40		$2,260 Med/Surg \| $2,920 ICU/CCU	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	80% of Billed Charges			65% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant and Ends at Discharge	Ends One (1) Year from Discharge		42.3144556	-71.0403236	286.pdf
Massachusetts General Hospital	Transplant	Boston	MA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceELITE	Hospital: $155,000 \| Professional: 80% of Billed Charges	45		$2,260 Med/Surg \| $2,920 ICU/CCU	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			65% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant and Ends at Discharge	Ends One (1) Year from Discharge		42.3144556	-71.0403236	286.pdf
Massachusetts General Hospital	Transplant	Boston	MA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceELITE	Hospital: $100,000 \| Professional: 80% of Billed Charges	30		$2,260 Med/Surg \| $2,920 ICU/CCU	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			65% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant and Ends at Discharge	Ends One (1) Year from Discharge		42.3144556	-71.0403236	286.pdf
Massachusetts General Hospital	Transplant	Boston	MA	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $150,000 \| Professional: 80% of Billed Charges	20		$2,260 Med/Surg \| $2,920 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	80% of Billed Charges	65% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant and Ends at Discharge	Ends One (1) Year from Discharge		42.3144556	-71.0403236	287.pdf
Massachusetts General Hospital	Transplant	Boston	MA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Hospital (Cadaveric Donor): $62,500 \| Hospital (Living Donor): $67,800 \| Professional Services: 80% of Billed Charges	15		$2,260 Med/Surg \| $2,920 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	N/A	65% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant and Ends at Discharge	Ends One (1) Year from Discharge		42.3144556	-71.0403236	288.pdf
Massachusetts General Hospital	Transplant	Boston	MA	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $155,000 \| Professional: 80% of Billed Charges	22		$2,260 Med/Surg \| $2,920 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	N/A	65% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant and Ends at Discharge	Ends One (1) Year from Discharge		42.3144556	-71.0403236	289.pdf
Massachusetts General Hospital	Transplant	Boston	MA	Lung	Lung	Adult	Member's Choice		Hospital (Single Lung): $140,000 \| Hospital (Double Lung): $175,000 \| Professional Services: 80% of Billed Charges	25		$2,260 Med/Surg \| $2,920 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	N/A	65% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant and Ends at Discharge	Ends One (1) Year from Discharge		42.3144556	-71.0403236	290.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$98,000	N/A		N/A	95% of Billed Charges	Hospital: 90% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		33.6056711	-112.4052341	311.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor: $48,000 \| Living Donor: $62,000	N/A		N/A	95% of Billed Charges	Hospital: 90% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		33.6056711	-112.4052341	312.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceELITE	$98,000	N/A		N/A	95% of Billed Charges	Hospital: 90% of Billed Charges \|Professional: 75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		33.6056711	-112.4052341	313.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor: $128,000 \| Living Donor: $158,000	N/A		N/A	95% of Billed Charges	Hospital: 90% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		33.6056711	-112.4052341	314.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	$69,000	50		N/A	95% of Billed Charges	Hospital: 90% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate During Inlier Day's Period; Reimbused at Pre-Transplant Rate if Provided Prior to Inlier Period	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Date of Initial Infusion		33.6056711	-112.4052341	315.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	$138,000	100		N/A	95% of Billed Charges	Hospital: 90% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate During Inlier Day's Period; Reimbused at Pre-Transplant Rate if Provided Prior to Inlier Period	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Date of Initial Infusion		33.6056711	-112.4052341	315.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	Matched: $118000 \| Mismatched: $138,000	100		N/A	95% of Billed Charges	Hospital: 90% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate During Inlier Day's Period; Reimbused at Pre-Transplant Rate if Provided Prior to Inlier Period	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Date of Initial Infusion		33.6056711	-112.4052341	315.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Lung	Lung	Adult	Member's Choice		$104,000	N/A		N/A	95% of Billed Charges	Hospital: 90% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, Then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		33.6056711	-112.4052341	316.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Pancreas	Pancreas	Adult	Programs of Excellence		$69,000	N/A		N/A	95% of Billed Charges	Hospital: 90% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		33.6056711	-112.4052341	317.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Multi-Organ	Multi-Organ	Adult	Member's Choice		100% of the Higher Cost Organ + 50% of the Lower Cost Organ	N/A		N/A	95% of Billed Charges	Hospital: 90% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges		Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge	33.6056711	-112.4052341	318.pdf
Mayo Clinic Arizona	Cellular Immunotherapy	Phoenix	AZ	Cellular Immunotherapy	Cellular Immunotherapy				75% of Billed Charges \| Drug Cost: 110% of Invoice Cost	N/A	90% of Billed Charges Drug Cost: 110% of Invoice Cost	N/A	N/A	90% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends One (1) Year from Discharge		33.6050976	-112.4059148	319.pdf
Mayo Clinic Arizona	Cancer	Phoenix	AZ	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															33.6050976	-112.4059148	320.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Heart	Heart	Adult	Government Rates		$98,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		33.6056711	-112.4052341	321.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Kidney	Kidney	Adult	Government Rates		Cadaveric Donor: $48,000 \| Living Donor: $62,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate. Kidneys may be billed directly to Medicare instead of Payor and would be excluded from this agreement in that context.	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		33.6056711	-112.4052341	322.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates		$98,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate. Kidneys may be billed directly to Medicare instead of Payor and would be excluded from this agreement in that context.	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		33.6056711	-112.4052341	323.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Liver	Liver	Adult	Government Rates		Cadaveric Donor: $128,000 \| Living Donor: $158,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		33.6056711	-112.4052341	324.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates		$69,000	50		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered	Included in Case Rate During Inlier Day's Period; Reimbused at Pre-Transplant Rate if Provided Prior to Inlier Period	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Date of Initial Infusion		33.6056711	-112.4052341	325.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Government Rates		$138,000	100		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered	Included in Case Rate During Inlier Day's Period; Reimbused at Pre-Transplant Rate if Provided Prior to Inlier Period	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Date of Initial Infusion		33.6056711	-112.4052341	325.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates		Matched: $118000 \| Mismatched: $138,000	100		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered	Included in Case Rate During Inlier Day's Period; Reimbused at Pre-Transplant Rate if Provided Prior to Inlier Period	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Date of Initial Infusion		33.6056711	-112.4052341	325.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Pancreas	Pancreas	Adult	Government Rates		$69,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		33.6056711	-112.4052341	326.pdf
Mayo Clinic Arizona	Transplant	Phoenix	AZ	Multi-Organ	Multi-Organ	Adult	Government Rates		100% of the Higher Cost Organ + 50% of the Lower Cost Organ	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate. Kidneys may be billed directly to Medicare instead of Payor and would be excluded from this agreement in that context.	N/A	70% of Billed Charges		Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge	33.6056711	-112.4052341	327.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	Matched Donor: $118,000 \| Mismatched Donor: $138,000	100		N/A	95% of Billed Charges	75% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period. If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins Ten Days Prior to the Initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		30.3452116	-81.8231908	291.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$138,000	100		N/A	95% of Billed Charges	75% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period. If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins Ten Days Prior to the Initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		30.3452116	-81.8231908	291.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$69,000	50		N/A	95% of Billed Charges	75% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period. If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins Ten Days Prior to the Initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		30.3452116	-81.8231908	291.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		Matched Donor: $118,000 \| Mismatched Donor: $138,000	100		N/A	95% of Billed Charges	75% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period. If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins Ten Days Prior to the Initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		30.3452116	-81.8231908	291.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$138,000	100		N/A	95% of Billed Charges	75% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period. If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins Ten Days Prior to the Initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		30.3452116	-81.8231908	291.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$69,000	50		N/A	95% of Billed Charges	75% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period. If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins Ten Days Prior to the Initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		30.3452116	-81.8231908	291.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Heart	Heart	Adult	Programs of Excellence	PerformanceELITE	$98,000	N/A		N/A	95% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, Then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		30.3452116	-81.8231908	292.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Heart/Lung	Heart/Lung	Adult	Member's Choice		$114,000	N/A		N/A	95% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, Then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		30.3452116	-81.8231908	293.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor: $48,000 \| Living Donor: $62,000	N/A		N/A	95% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, Then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		30.3452116	-81.8231908	294.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$98,000	N/A		N/A	95% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, Then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		30.3452116	-81.8231908	295.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor: $128,000 \| Living Donor: $158,000	N/A		N/A	95% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, Then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		30.3452116	-81.8231908	296.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	$104,000	N/A		N/A	95% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, Then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		30.3452116	-81.8231908	297.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Pancreas	Pancreas	Adult	Programs of Excellence		$69,000	N/A		N/A	95% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, Then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		30.3452116	-81.8231908	298.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Multi-Organ	Multi-Organ	Adult	Member's Choice		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	N/A		N/A	95% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, Then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		30.3452116	-81.8231908	299.pdf
Mayo Clinic Florida	Cellular Immunotherapy	Jacksonville	FL	Cellular Immunotherapy	Cellular Immunotherapy				75% of Billed Charges \| Drug Cost: 110% of Invoice Cost	N/A		N/A	N/A	75% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins at Evaluation for CAR-T Therapy Treament and Ends at Discharge	Ends One (1) Year from Discharge		30.344915	-81.8235326	300.pdf
Mayo Clinic Florida	Cancer	Jacksonville	FL	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															30.344915	-81.8235326	301.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates		Matched Donor: $118,000 \| Mismatched Donor: $138,000	100		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period. If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins Ten Days Prior to the Initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		30.3452116	-81.8231908	302.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Government Rates		$138,000	100		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period. If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins Ten Days Prior to the Initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		30.3452116	-81.8231908	302.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates		$69,000	50		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period. If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins Ten Days Prior to the Initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		30.3452116	-81.8231908	302.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Government Rates		Matched Donor: $118,000 \| Mismatched Donor: $138,000	100		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period. If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins Ten Days Prior to the Initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		30.3452116	-81.8231908	302.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Government Rates		$138,000	100		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period. If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins Ten Days Prior to the Initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		30.3452116	-81.8231908	302.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Blood/Marrow (Autologous)	Autologous	Pediatric	Government Rates		$69,000	50		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period. If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins Ten Days Prior to the Initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		30.3452116	-81.8231908	302.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Heart	Heart	Adult	Government Rates		$98,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, Then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		30.3452116	-81.8231908	303.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Heart/Lung	Heart/Lung	Adult	Government Rates		$114,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, Then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		30.3452116	-81.8231908	304.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Kidney	Kidney	Adult	Government Rates		Cadaveric Donor: $48,000 \| Living Donor: $62,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate. Kidneys may be billed directly to Medicare instead of Payor and would be excluded from this agreement in that context.	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, Then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		30.3452116	-81.8231908	305.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates		$98,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate. Kidneys may be billed directly to Medicare instead of Payor and would be excluded from this agreement in that context.	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, Then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		30.3452116	-81.8231908	306.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Liver	Liver	Adult	Government Rates		Cadaveric Donor: $128,000 \| Living Donor: $158,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, Then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		30.3452116	-81.8231908	307.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Lung	Lung	Adult	Government Rates		$104,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, Then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		30.3452116	-81.8231908	308.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Pancreas	Pancreas	Adult	Government Rates		$69,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, Then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		30.3452116	-81.8231908	309.pdf
Mayo Clinic Florida	Transplant	Jacksonville	FL	Multi-Organ	Multi-Organ	Adult	Government Rates		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate. Kidneys may be billed directly to Medicare instead of Payor and would be excluded from this agreement in that context.	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, Then the Transplant Phase Begins at Admission and Ends at Discharge	Ends 365 Days from Discharge		30.3452116	-81.8231908	310.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Heart/Lung	Heart/Lung	Adult	Member's Choice		$114,000	N/A		N/A	95% of Billed Charges	95% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	428.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	$98,000	N/A		N/A	95% of Billed Charges	95% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	429.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	$104,000	N/A		N/A	95% of Billed Charges	95% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	430.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	Matched Donor: $118,000 \| Mismatched Donor: $138,000	100		N/A	95% of Billed Charges	95% of Billed Charges	Included in Case Rate	N/A			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		43.996149	-92.6212551	431.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	$138,000	100		N/A	95% of Billed Charges	95% of Billed Charges	Included in Case Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		43.996149	-92.6212551	431.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	$69,000	50		N/A	95% of Billed Charges	95% of Billed Charges	Included in Case Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		43.996149	-92.6212551	431.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		Matched Donor: $118,000 \| Mismatched Donor: $138,000	100		N/A	95% of Billed Charges	95% of Billed Charges	Included in Case Rate	N/A			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		43.996149	-92.6212551	431.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$138,000	100		N/A	95% of Billed Charges	95% of Billed Charges	Included in Case Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		43.996149	-92.6212551	431.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$69,000	50		N/A	95% of Billed Charges	95% of Billed Charges	Included in Case Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		43.996149	-92.6212551	431.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$98,000	N/A		N/A	95% of Billed Charges	95% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	432.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Heart	Heart	Pediatric	Programs of Excellence		$98,000	N/A		N/A	95% of Billed Charges	95% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	432.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor: $48,000 \| Living Donor: $62,000	N/A		N/A	95% of Billed Charges	95% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	433.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Kidney	Kidney	Pediatric	Programs of Excellence		Cadaveric Donor: $48,000 \| Living Donor: $62,000	N/A		N/A	95% of Billed Charges	95% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	433.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor: $128,000 \| Living Donor: $158,000	N/A		N/A	95% of Billed Charges	95% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	434.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Liver	Liver	Pediatric	Member's Choice		Cadaveric Donor: $128,000 \| Living Donor: $158,000	N/A		N/A	95% of Billed Charges	95% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	434.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Multi-Organ	Multi-Organ	Adult	Member's Choice		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	N/A		N/A	95% of Billed Charges	95% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	435.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Pancreas	Pancreas	Adult	Programs of Excellence		$69,000	N/A		N/A	95% of Billed Charges	95% of Billed Charges	Included in Case Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		43.996149	-92.6212551	436.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Multi-Organ	Multi-Organ	Pediatric	Member's Choice		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	N/A		N/A	95% of Billed Charges	95% of Billed Charges			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	437.pdf
Mayo Clinic Rochester	Cellular Immunotherapy	Rochester	MN	Cellular Immunotherapy	Cellular Immunotherapy				95% of Billed Charges \| Drug Cost: 110% of Invoice Cost	N/A		N/A	N/A	95% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins at Evaluation for CAR-T Therapy Treament and Ends at Discharge	Ends One (1) Year from Discharge		43.9959661	-92.5513833	438.pdf
Mayo Clinic Rochester	Cancer	Rochester	MN	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															43.9959661	-92.5513833	439.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Heart/Lung	Heart/Lung	Adult	Government Rates		$114,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	440.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates		$98,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate. Kidneys may be billed directly to Medicare instead of Payor and would be excluded from this agreement in that context.	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	441.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Lung	Lung	Adult	Government Rates		$104,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	442.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates		Matched Donor: $118,000 \| Mismatched Donor: $138,000	100		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered	Included in Case Rate	N/A			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		43.996149	-92.6212551	443.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Government Rates		$138,000	100		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered	Included in Case Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		43.996149	-92.6212551	443.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates		$69,000	50		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered	Included in Case Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		43.996149	-92.6212551	443.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Government Rates		Matched Donor: $118,000 \| Mismatched Donor: $138,000	100		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered	Included in Case Rate	N/A			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		43.996149	-92.6212551	443.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Government Rates		$138,000	100		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered	Included in Case Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		43.996149	-92.6212551	443.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Blood/Marrow (Autologous)	Autologous	Pediatric	Government Rates		$69,000	50		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered	Included in Case Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		43.996149	-92.6212551	443.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Heart	Heart	Adult	Government Rates		$98,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	444.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Heart	Heart	Pediatric	Government Rates		$98,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	444.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Kidney	Kidney	Adult	Government Rates		Cadaveric Donor: $48,000 \| Living Donor: $62,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate. Kidneys may be billed directly to Medicare instead of Payor and would be excluded from this agreement in that context.	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	445.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Kidney	Kidney	Pediatric	Government Rates		Cadaveric Donor: $48,000 \| Living Donor: $62,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate. Kidneys may be billed directly to Medicare instead of Payor and would be excluded from this agreement in that context.	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	445.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Liver	Liver	Adult	Government Rates		Cadaveric Donor: $128,000 \| Living Donor: $158,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	446.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Liver	Liver	Pediatric	Government Rates		Cadaveric Donor: $128,000 \| Living Donor: $158,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	446.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Multi-Organ	Multi-Organ	Adult	Government Rates		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate. Kidneys may be billed directly to Medicare instead of Payor and would be excluded from this agreement in that context.	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	447.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Multi-Organ	Multi-Organ	Pediatric	Government Rates		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered			Included in Case Rate. Kidneys may be billed directly to Medicare instead of Payor and would be excluded from this agreement in that context.	N/A	70% of Billed Charges	Begins at Evaluation	Begins on the Day of Transplant, Unless Patient is Admitted One (1) Day Prior to Transplant, then the Transplant Phase Begins at Admission	Ends 365 Days from Discharge		43.996149	-92.6212551	447.pdf
Mayo Clinic Rochester	Transplant	Rochester	MN	Pancreas	Pancreas	Adult	Government Rates		$69,000	N/A		N/A	95% of Billed Charges	130% of Medicare Allowable, current on date services were rendered	Included in Case Rate	Included in Case Rate			70% of Billed Charges	Begins at Evaluation	Begins 10 Days Prior to the initial Infusion Date and Ends when the Inlier Days have Expired	Ends 365 Days from Discharge		43.996149	-92.6212551	448.pdf
MD Anderson Cancer Center	Transplant	Houston	TX	Blood/Marrow (Autologous, Breast Cancer)	Autologous	Adult	Programs of Excellence	PerformanceELITE	$84,360	30		$3,500 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	85% of Billed Charges	Routine Harvest: $10,000 \| Complex Harvest: $20,000	Invoice Cost, Plus 10%			65% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.8171037	-95.5417172	328.pdf
MD Anderson Cancer Center	Transplant	Houston	TX	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceELITE	$96,900	30		$3,500 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	85% of Billed Charges	Routine Harvest: $10,000 \| Complex Harvest: $20,000	Invoice Cost, Plus 10%			65% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.8171037	-95.5417172	328.pdf
MD Anderson Cancer Center	Transplant	Houston	TX	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceELITE	$133,380	40		$3,500 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	85% of Billed Charges	Routine Harvest: $10,000 \| Complex Harvest: $20,000	Invoice Cost, Plus 10%			65% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.8171037	-95.5417172	328.pdf
MD Anderson Cancer Center	Transplant	Houston	TX	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceELITE	$186,960	40		$3,500 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	85% of Billed Charges	85% of Billed Charges	Invoice Cost, Plus 10%			65% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.8171037	-95.5417172	328.pdf
MD Anderson Cancer Center	Cancer	Houston	TX	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															29.8171037	-95.5417172	329.pdf
MD Anderson Cancer Center	Cellular Immunotherapy	Houston	TX	Cellular Immunotherapy	Cellular Immunotherapy				75% of Billed Charges \| Drug Cost: 100% of Invoice Cost	N/A		N/A	N/A	75% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends 365 Days from Discharge		29.8171037	-95.5417172	330.pdf
Medical University of South Carolina	Destination VAD	Columbia	SC	Destination VAD	Destination VAD				$143,100	N/A		N/A	95% of Billed Charges	75% of Billed Charges				55% of Billed Charges	$286,200 & 70% of Billed Charges Thereafter	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		34.037489	-81.0077761	331.pdf
Medical University of South Carolina	Transplant	Columbia	SC	Heart	Heart	Adult	Programs of Excellence	PerformanceELITE	$143,100	N/A		N/A	Lesser of 95%	75% of Billed Charges			Charges Reimbursed at Cost Pass Through	Reimbursed at 55% of Billed Charges	70% of Billed Charges in Excess of the Threshold ($286,200)	Begins at Evaluation	Begins One (1) Day Prior to Admission and Ends at Discharge	Ends One (1) Year from Discharge		34.037489	-81.0077761	331.pdf
Medical University of South Carolina	Transplant	Columbia	SC	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor: $159,000 \| Living Donor: 70% of Billed Charges	N/A		N/A	Lesser of 95%	75% of Billed Charges			Cadaveric Donor: Reimbursed at Cost Pass Through \| Living Donor: 70% of Billed Charges	Reimbursed at 55% of Billed Charges	70% of Billed Charges in Excess of the Threshold ($318,000)	Begins at Evaluation	Begins One (1) Day Prior to Admission and Ends at Discharge	Ends One (1) Year from Discharge		34.037489	-81.0077761	332.pdf
Medical University of South Carolina	Transplant	Columbia	SC	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	$106,000	N/A		N/A	Lesser of 95%	75% of Billed Charges	Included in Case Rate	N/A			70% of Billed Charges in Excess of the Threshold ($159,000)	Begins at Evaluation	Begins on the Day of Mobilization Therapy and Ends at Discharge	Ends One (1) Year from Discharge		34.037489	-81.0077761	333.pdf
Medical University of South Carolina	Transplant	Columbia	SC	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	$153,700	N/A		N/A	Lesser of 95%	75% of Billed Charges	Included in Case Rate	N/A			70% of Billed Charges in Excess of the Threshold ($230,550)	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		34.037489	-81.0077761	333.pdf
Medical University of South Carolina	Transplant	Columbia	SC	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	$196,100	N/A		N/A	Lesser of 95%	75% of Billed Charges	Included in Case Rate	Charges Reimbursed at Invoice Cost			70% of Billed Charges in Excess of the Threshold ($294,150)	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		34.037489	-81.0077761	333.pdf
Medical University of South Carolina	Transplant	Columbia	SC	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Programs of Excellence	PerformanceSELECT	$196,100	N/A		N/A	Lesser of 95%	75% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			70% of Billed Charges in Excess of the Threshold ($294,150)	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		34.037489	-81.0077761	333.pdf
Medical University of South Carolina	Transplant	Columbia	SC	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$47,700	N/A		N/A	Lesser of 95%	75% of Billed Charges			Charges Reimbursed at Cost Pass Through	Reimbursed at 55% of Billed Charges	70% of Billed Charges in Excess of the Threshold ($95,400)	Begins at Evaluation	Begins One (1) Day Prior to Admission and Ends at Discharge	Ends One (1) Year from Discharge		34.037489	-81.0077761	334.pdf
Medical University of South Carolina	Transplant	Columbia	SC	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	$127,700	N/A		N/A	Lesser of 95%	75% of Billed Charges			Charges Reimbursed at Cost Pass Through	Reimbursed at 55% of Billed Charges	70% of Billed Charges in Excess of the Threshold ($201,400)	Begins at Evaluation	Begins One (1) Day Prior to Admission and Ends at Discharge	Ends One (1) Year from Discharge		34.037489	-81.0077761	335.pdf
Medical University of South Carolina	Transplant	Columbia	SC	Pancreas	Pancreas	Adult	Programs of Excellence		$110,000	N/A		N/A	Lesser of 95%	75% of Billed Charges			Charges Reimbursed at Cost Pass Through	Reimbursed at 55% of Billed Charges	70% of Billed Charges in Excess of the Threshold ($180,200)	Begins at Evaluation	Begins One (1) Day Prior to Admission and Ends at Discharge	Ends One (1) Year from Discharge		34.037489	-81.0077761	336.pdf
Medical University of South Carolina	Transplant	Columbia	SC	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	$180,000	N/A		N/A	Lesser of 95%	75% of Billed Charges			Charges Reimbursed at Cost Pass Through	Reimbursed at 55% of Billed Charges	70% of Billed Charges in Excess of the Threshold ($320,000)	Begins at Evaluation	Begins One (1) Day Prior to Admission and Ends at Discharge	Ends One (1) Year from Discharge		34.037489	-81.0077761	337.pdf
Medical University of South Carolina (CAR-T)	Cellular Immunotherapy	Columbia	SC	Cellular Immunotherapy	Cellular Immunotherapy																			34.037489	-81.0077761	338.pdf
Medical University of South Carolina (Gene Therapy)	Cellular Immunotherapy	Columbia	SC	Cellular Immunotherapy	Cellular Immunotherapy																			34.037489	-81.0077761	339.pdf
Medstar Georgetown Transplant Institute	Transplant	Washington, DC	DC	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$90,000	15		$3,000 Med/Surg \| $3,500 ICU/CCU	95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 70% of Billed Charges	If Billed Charges Exceed $150,000, Payment will be the Transplant Case Rate plus any applicable Outlier Days, Plus 65% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Inlier and applicable Outlier Days		38.8937091	-77.0846157	340.pdf
Medstar Georgetown Transplant Institute	Transplant	Washington, DC	DC	Kidney	Kidney	Pediatric	Member's Choice		$90,000	15		$3,000 Med/Surg \| $3,500 ICU/CCU	95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 70% of Billed Charges	If Billed Charges Exceed $150,000, Payment will be the Transplant Case Rate plus any applicable Outlier Days, Plus 65% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Inlier and applicable Outlier Days		38.8937091	-77.0846157	340.pdf
Medstar Georgetown Transplant Institute	Transplant	Washington, DC	DC	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	$135,000	20		$3,000 Med/Surg \| $3,500 ICU/CCU	95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 70% of Billed Charges	If Billed Charges Exceed $230,000, Payment will be the Transplant Case Rate plus any applicable Outlier Days, Plus 65% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Inlier and applicable Outlier Days		38.8937091	-77.0846157	341.pdf
Medstar Georgetown Transplant Institute	Transplant	Washington, DC	DC	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor: $200,000 \| Living Donor: $210,000	20 \| 25		$3,000 Med/Surg \| $3,500 ICU/CCU	95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 70% of Billed Charges	If Billed Charges Exceed $340,000 (Cadaveric) or $360,000 (Living), Payment will be the Transplant Case Rate plus any applicable Outlier Days, Plus 65% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Inlier and applicable Outlier Days		38.8937091	-77.0846157	342.pdf
Medstar Georgetown Transplant Institute	Transplant	Washington, DC	DC	Pancreas	Pancreas	Adult	Programs of Excellence		$100,000	16		$3,000 Med/Surg \| $3,500 ICU/CCU	95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 70% of Billed Charges	If Billed Charges Exceed $170,000, Payment will be the Transplant Case Rate plus any applicable Outlier Days, Plus 65% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Inlier and applicable Outlier Days		38.8937091	-77.0846157	343.pdf
Medstar Georgetown Transplant Institute	Transplant	Washington, DC	DC	Pancreas	Pancreas	Pediatric	Programs of Excellence		$100,000	16		$3,000 Med/Surg \| $3,500 ICU/CCU	95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 70% of Billed Charges	If Billed Charges Exceed $170,000, Payment will be the Transplant Case Rate plus any applicable Outlier Days, Plus 65% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Inlier and applicable Outlier Days		38.8937091	-77.0846157	343.pdf
Medstar Georgetown Transplant Institute	Transplant	Washington, DC	DC	Intestine	Intestine	Pediatric	Programs of Excellence		70% of Billed Charges	N/A		N/A	N/A	N/A			Included in Transplant Rate	Reimbursed at 70% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		38.8937091	-77.0846157	344.pdf
Medstar Georgetown Transplant Institute	Transplant	Washington, DC	DC	Intestine	Intestine	Adult	Programs of Excellence		70% of Billed Charges	N/A		N/A	N/A	N/A			Included in Transplant Rate	Reimbursed at 70% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		38.8937091	-77.0846157	344.pdf
Medstar Georgetown Transplant Institute	Transplant	Washington, DC	DC	Liver	Liver	Pediatric	Programs of Excellence		Cadaveric Donor: $220,000 \| Living Donor: $230,000	20 \| 25		$3,000 Med/Surg \| $3,500 ICU/CCU	95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 70% of Billed Charges	If Billed Charges Exceed $375,000 (Cadaveric) or $390,000 (Living), Payment will be the Transplant Case Rate plus any applicable Outlier Days, Plus 65% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Inlier and applicable Outlier Days		38.8937091	-77.0846157	345.pdf
Medstar Georgetown Transplant Institute	Transplant	Washington, DC	DC	Multi-Visceral	Multi-Visceral	Pediatric	Programs of Excellence		70% of Billed Charges	N/A		N/A	N/A	N/A			Included in Transplant Rate	Reimbursed at 70% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		38.8937091	-77.0846157	346.pdf
Medstar Georgetown Transplant Institute	Transplant	Washington, DC	DC	Multi-Visceral	Multi-Visceral	Adult	Member's Choice		70% of Billed Charges	N/A		N/A	N/A	N/A			Included in Transplant Rate	Reimbursed at 70% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		38.8937091	-77.0846157	346.pdf
Memorial Sloan Kettering Cancer Center	Transplant	New York	NY	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$286,379	50	Same Rate but 20 Days from Infusion Date	Hospital: $5,967 Med/Surg/ICU/CCU \| Professional: 90% of Billed Charges	90% of Billed Charges	Hospital Inpatient Services and Supplies Shall be Reimbursed at the Lesser of 90% of Billed Charges or a Per Diem Rate of $4,862 or for an Inpatient Stay that Includes Surgery, a Per Diem Rate of $7,276 Professional Inpatient Services Shall be Reimbursed at 90% of Billed Charges \| Hospital and Professional Outpatient Services and Supplies Shall be Reimbursed 90% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost		N/A	Any Pharmaceutical Charges (Revenue Code 636 and 25X) that Exceed $100,000 Shall be Reimbursed at 90% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		40.697403	-74.1201058	347.pdf
Memorial Sloan Kettering Cancer Center	Transplant	New York	NY	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$286,379	50	Same Rate but 20 Days from Infusion Date	Hospital: $5,967 Med/Surg/ICU/CCU \| Professional: 90% of Billed Charges	90% of Billed Charges	Hospital Inpatient Services and Supplies Shall be Reimbursed at the Lesser of 90% of Billed Charges or a Per Diem Rate of $4,862 or for an Inpatient Stay that Includes Surgery, a Per Diem Rate of $7,276 Professional Inpatient Services Shall be Reimbursed at 90% of Billed Charges \| Hospital and Professional Outpatient Services and Supplies Shall be Reimbursed 90% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost		N/A	Any Pharmaceutical Charges (Revenue Code 636 and 25X) that Exceed $100,000 Shall be Reimbursed at 90% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		40.697403	-74.1201058	347.pdf
Memorial Sloan Kettering Cancer Center	Transplant	New York	NY	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$139,230	35	Same Rate but 20 Days from Infusion Date	Hospital: $5,967 Med/Surg/ICU/CCU \| Professional: 90% of Billed Charges	90% of Billed Charges	Hospital Inpatient Services and Supplies Shall be Reimbursed at the Lesser of 90% of Billed Charges or a Per Diem Rate of $4,862 or for an Inpatient Stay that Includes Surgery, a Per Diem Rate of $7,276 Professional Inpatient Services Shall be Reimbursed at 90% of Billed Charges \| Hospital and Professional Outpatient Services and Supplies Shall be Reimbursed 90% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost		N/A	Any Pharmaceutical Charges (Revenue Code 636 and 25X) that Exceed $100,000 Shall be Reimbursed at 90% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		40.697403	-74.1201058	347.pdf
Memorial Sloan Kettering Cancer Center	Transplant	New York	NY	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$286,379	50	Same Rate but 20 Days from Infusion Date	Hospital: $5,967 Med/Surg/ICU/CCU \| Professional: 90% of Billed Charges	90% of Billed Charges	Hospital Inpatient Services and Supplies Shall be Reimbursed at the Lesser of 90% of Billed Charges or a Per Diem Rate of $4,862 or for an Inpatient Stay that Includes Surgery, a Per Diem Rate of $7,276 Professional Inpatient Services Shall be Reimbursed at 90% of Billed Charges \| Hospital and Professional Outpatient Services and Supplies Shall be Reimbursed 90% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost		N/A	Any Pharmaceutical Charges (Revenue Code 636 and 25X) that Exceed $100,000 Shall be Reimbursed at 90% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		40.697403	-74.1201058	347.pdf
Memorial Sloan Kettering Cancer Center	Transplant	New York	NY	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$286,379	50	Same Rate but 20 Days from Infusion Date	Hospital: $5,967 Med/Surg/ICU/CCU \| Professional: 90% of Billed Charges	90% of Billed Charges	Hospital Inpatient Services and Supplies Shall be Reimbursed at the Lesser of 90% of Billed Charges or a Per Diem Rate of $4,862 or for an Inpatient Stay that Includes Surgery, a Per Diem Rate of $7,276 Professional Inpatient Services Shall be Reimbursed at 90% of Billed Charges \| Hospital and Professional Outpatient Services and Supplies Shall be Reimbursed 90% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost		N/A	Any Pharmaceutical Charges (Revenue Code 636 and 25X) that Exceed $100,000 Shall be Reimbursed at 90% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		40.697403	-74.1201058	347.pdf
Memorial Sloan Kettering Cancer Center	Transplant	New York	NY	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$139,230	35	Same Rate but 20 Days from Infusion Date	Hospital: $5,967 Med/Surg/ICU/CCU \| Professional: 90% of Billed Charges	90% of Billed Charges	Hospital Inpatient Services and Supplies Shall be Reimbursed at the Lesser of 90% of Billed Charges or a Per Diem Rate of $4,862 or for an Inpatient Stay that Includes Surgery, a Per Diem Rate of $7,276 Professional Inpatient Services Shall be Reimbursed at 90% of Billed Charges \| Hospital and Professional Outpatient Services and Supplies Shall be Reimbursed 90% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost		N/A	Any Pharmaceutical Charges (Revenue Code 636 and 25X) that Exceed $100,000 Shall be Reimbursed at 90% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		40.697403	-74.1201058	347.pdf
Memorial Sloan Kettering Cancer Center	Cellular Immunotherapy	New York	NY	Cellular Immunotherapy	Cellular Immunotherapy				Charges $0 - $1,000,000 Pay at 65% \| Charges $1,000,001 and Above Pay at 60% \| Drug Cost: 100% of Invoice Cost	N/A		N/A	N/A	65% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	348.pdf
Memorial Sloan Kettering Cancer Center	Cancer	New York	NY	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															40.697403	-74.1201058	349.pdf
Methodist Dallas Medical Center	Transplant	Dallas	TX	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		$317,393	16		$4,915 Med/Surg \| $5,926 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		32.8205862	-96.871968	350.pdf
Methodist Dallas Medical Center	Transplant	Dallas	TX	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	$255,236	15		$4,915 Med/Surg \| $5,926 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		32.8205862	-96.871968	351.pdf
Methodist Dallas Medical Center	Transplant	Dallas	TX	Kidney	Kidney	Adult	Member's Choice		Cadaveric Donor: $113,046 \| Living Donor: $104,125	10		$4,915 Med/Surg \| $5,926 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		32.8205862	-96.871968	352.pdf
Methodist Dallas Medical Center	Transplant	Dallas	TX	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$186,504	12		$4,915 Med/Surg \| $5,926 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		32.8205862	-96.871968	353.pdf
Methodist University Hospital	Transplant	Memphis	TN	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor: $64,000 \| Living Donor: $68,000	13		$2,000 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends One (1) Year from Discharge		35.129105	-90.1112123	354.pdf
Methodist University Hospital	Transplant	Memphis	TN	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	$149,900	22		$2,000 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends One (1) Year from Discharge		35.129105	-90.1112123	355.pdf
Methodist University Hospital	Transplant	Memphis	TN	Pancreas	Pancreas	Adult	Programs of Excellence		$87,000	15		$2,000 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends One (1) Year from Discharge		35.129105	-90.1112123	356.pdf
Methodist University Hospital	Transplant	Memphis	TN	Kidney	Kidney	Pediatric	Member's Choice		$69,000	15		$2,000 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends One (1) Year from Discharge		35.129105	-90.1112123	357.pdf
Methodist University Hospital	Transplant	Memphis	TN	Liver	Liver	Pediatric	Member's Choice		$155,000	24		$2,000 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	Inpatient Hospital: $2,916 (Med/Surg), $3,240 (ICU/CCU) \| All Other: 75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends One (1) Year from Discharge		35.129105	-90.1112123	358.pdf
Methodist University Hospital	Transplant	Memphis	TN	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	$101,000	17		$2,000 Med/Surg:$2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends One (1) Year from Discharge		35.129105	-90.1112123	359.pdf
Moffitt Cancer Center	Transplant	Tampa	FL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceELITE	$125,000	90		N/A	90% of Billed Charges	70% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days	Charges Included in the Transplant Case Rate if Provided During the Inlier Days			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year following Inlier Days period		27.9947147	-82.5943645	360.pdf
Moffitt Cancer Center	Transplant	Tampa	FL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceELITE	$145,000	90		N/A	90% of Billed Charges	70% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days	Charges Included in the Transplant Case Rate if Provided During the Inlier Days			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year following Inlier Days period		27.9947147	-82.5943645	360.pdf
Moffitt Cancer Center	Transplant	Tampa	FL	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceELITE	$75,000	60		N/A	90% of Billed Charges	70% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days	Charges Included in the Transplant Case Rate if Provided During the Inlier Days			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year following Inlier Days period		27.9947147	-82.5943645	360.pdf
Moffitt Cancer Center	Transplant	Tampa	FL	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Programs of Excellence	PerformanceELITE	$145,000	90		N/A	90% of Billed Charges	70% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days	Charges Included in the Transplant Case Rate if Provided During the Inlier Days			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year following Inlier Days period		27.9947147	-82.5943645	360.pdf
Moffitt Cancer Center	Transplant	Tampa	FL	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Adult	Programs of Excellence	PerformanceELITE	1st Infusion: $75,000 \| 2nd Infusion: $95,000	1st Infusion: 120 \| 2nd Infusion: 60		N/A	90% of Billed Charges	70% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days	Charges Included in the Transplant Case Rate if Provided During the Inlier Days			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year following Inlier Days period		27.9947147	-82.5943645	360.pdf
Moffitt Cancer Center	Cellular Immunotherapy	Tampa	FL	Cellular Immunotherapy	Cellular Immunotherapy																			27.9947147	-82.5943645	869.pdf
Moffitt Cancer Center	Cancer	Tampa	FL	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															27.9944112	-82.5947063	361.pdf
Moffitt Cancer Center (Managed Medicaid)	Cellular Immunotherapy	Tampa	FL	Cellular Immunotherapy	Cellular Immunotherapy																			27.9947147	-82.5943645	871.pdf
Moffitt Cancer Center (Managed Medicaid)	Transplant	Tampa	FL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates																	27.9947147	-82.5943645	873.pdf
Moffitt Cancer Center (Managed Medicaid)	Transplant	Tampa	FL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Government Rates																	27.9947147	-82.5943645	873.pdf
Moffitt Cancer Center (Managed Medicaid)	Transplant	Tampa	FL	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates																	27.9947147	-82.5943645	873.pdf
Moffitt Cancer Center (Managed Medicaid)	Transplant	Tampa	FL	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Government Rates																	27.9947147	-82.5943645	873.pdf
Moffitt Cancer Center (Managed Medicaid)	Transplant	Tampa	FL	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Adult	Government Rates																	27.9947147	-82.5943645	873.pdf
Moffitt Cancer Center (Medicare Advantage)	Cellular Immunotherapy	Tampa	FL	Cellular Immunotherapy	Cellular Immunotherapy																			27.9947147	-82.5943645	870.pdf
Moffitt Cancer Center (Medicare Advantage)	Transplant	Tampa	FL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates																	27.9947147	-82.5943645	872.pdf
Moffitt Cancer Center (Medicare Advantage)	Transplant	Tampa	FL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Government Rates																	27.9947147	-82.5943645	872.pdf
Moffitt Cancer Center (Medicare Advantage)	Transplant	Tampa	FL	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates																	27.9947147	-82.5943645	872.pdf
Moffitt Cancer Center (Medicare Advantage)	Transplant	Tampa	FL	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Government Rates																	27.9947147	-82.5943645	872.pdf
Moffitt Cancer Center (Medicare Advantage)	Transplant	Tampa	FL	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Adult	Government Rates																	27.9947147	-82.5943645	872.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Heart	Heart	Adult	Member's Choice		$493,136.13	24		$6,061.78 Med/Surg \| $8,478.16 ICU/CCU \| $3,881.48 Rehab	100% of Billed Charges or the Case Rate	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	362.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Heart	Heart	Pediatric	Member's Choice		$493,136.13	24		$6,061.78 Med/Surg \| $8,478.16 ICU/CCU \| $3,881.48 Rehab	100% of Billed Charges or the Case Rate	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	362.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Intestine	Intestine	Adult	Programs of Excellence		80% of Billed Charges	N/A		$6,061.78 Med/Surg \| $8,478.16 ICU/CCU \| $3,881.48 Rehab	100% of Billed Charges or the Case Rate	75% of Billed Charges				Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	363.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Intestine	Intestine	Pediatric	Member's Choice		80% of Billed Charges	N/A		N/A	100% of Billed Charges or the Case Rate	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	363.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$198,240.45	14		$6,061.78 Med/Surg \| $8,478.16 ICU/CCU \| $3,881.48 Rehab	100% of Billed Charges or the Case Rate	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	364.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Kidney	Kidney	Pediatric	Programs of Excellence		$198,240.45	14		$6,061.78 Med/Surg \| $8,478.16 ICU/CCU \| $3,881.48 Rehab	100% of Billed Charges or the Case Rate	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	364.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$289,285.24	20		$6,061.78 Med/Surg \| $8,478.16 ICU/CCU \| $3,881.48 Rehab	100% of Billed Charges or the Case Rate	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	365.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Kidney/Pancreas	Kidney/Pancreas	Pediatric	Member's Choice		$289,285.24	20		$6,061.78 Med/Surg \| $8,478.16 ICU/CCU \| $3,881.48 Rehab	100% of Billed Charges or the Case Rate	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	365.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor: $474,838.29 \| Living Donor: $548.053.24	Cadaveric: 38 \| Living: 38 (Recipient) \| Living: 7 (Donor)		$6,061.78 Med/Surg \| $8,478.16 ICU/CCU \| $3,881.48 Rehab	100% of Billed Charges or the Case Rate	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	366.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Liver	Liver	Pediatric	Programs of Excellence		Cadaveric Donor: $474,838.29 \| Living Donor: $548.053.24	Cadaveric: 38 \| Living: 38 (Recipient) \| Living: 7 (Donor)		$6,061.78 Med/Surg \| $8,478.16 ICU/CCU \| $3,881.48 Rehab	100% of Billed Charges or the Case Rate	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	366.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Lung	Lung	Adult	Member's Choice		Single: $479,325.26 \| Bilateral: $532,110.68	20		$6,061.78 Med/Surg \| $8,478.16 ICU/CCU \| $3,881.48 Rehab	100% of Billed Charges or the Case Rate	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	367.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Pancreas	Pancreas	Adult	Programs of Excellence		$257,608.43	15		$6,061.78 Med/Surg \| $8,478.16 ICU/CCU \| $3,881.48 Rehab	100% of Billed Charges or the Case Rate	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	368.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Pancreas	Pancreas	Pediatric	Programs of Excellence		$257,608.43	15		$6,061.78 Med/Surg \| $8,478.16 ICU/CCU \| $3,881.48 Rehab	100% of Billed Charges or the Case Rate	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	368.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Member's Choice		$298,575.81	40		$6,061.78 Med/Surg \| $8,478.16 ICU/CCU \| $3,881.48 Rehab	100% of Billed Charges or the Case Rate	75% of Billed Charges	Included in Case Rate	Included in Case Rate		Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	369.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Member's Choice		$335,897.77	47		$6,061.78 Med/Surg \| $8,478.16 ICU/CCU \| $3,881.48 Rehab	100% of Billed Charges or the Case Rate	75% of Billed Charges	Included in Case Rate	Included in Case Rate		Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	369.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Blood/Marrow (Autologous)	Autologous	Pediatric	Member's Choice		$232,734.76	35		$6,061.78 Med/Surg \| $8,478.16 ICU/CCU \| $3,881.48 Rehab	100% of Billed Charges or the Case Rate	75% of Billed Charges	Included in Case Rate	N/A		Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	369.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$298,575.81	40		$6,061.78 Med/Surg \| $8,478.16 ICU/CCU \| $3,881.48 Rehab	100% of Billed Charges or the Case Rate	75% of Billed Charges	Included in Case Rate	Included in Case Rate		Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	369.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$335,897.77	40		$6,061.78 Med/Surg \| $8,478.16 ICU/CCU \| $3,881.48 Rehab	100% of Billed Charges or the Case Rate	75% of Billed Charges	Included in Case Rate	Included in Case Rate		Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	369.pdf
Mount Sinai Medical Center	Transplant	New York	NY	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$232,734.76	35		$6,061.78 Med/Surg \| $8,478.16 ICU/CCU \| $3,881.48 Rehab	100% of Billed Charges or the Case Rate	75% of Billed Charges	Included in Case Rate	Included in Case Rate		Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	369.pdf
Mount Sinai Medical Center	Cellular Immunotherapy	New York	NY	Cellular Immunotherapy	Cellular Immunotherapy				$241,000 \| Drug Cost: 100% of Invoice Cost	35		$3,846 (Med/Surg) \| $5,384 (ICU/CCU) \| $2,461 (Hospital Rehab)	100% of Billed Charges	75% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends 365 Days from Discharge		40.697403	-74.1201058	370.pdf
Nemours Children's Hospital (Alfred I DuPont Hospital for Children)	Transplant	Wilmington	DE	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$135,000	30	Provisions the same as Inpatient	$3,100 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	95% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year post-Transplant		39.7299627	-75.5645038	371.pdf
Nemours Children's Hospital (Alfred I DuPont Hospital for Children)	Transplant	Wilmington	DE	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$185,000	30	Provisions the same as Inpatient	$3,100 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	95% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year post-Transplant		39.7299627	-75.5645038	371.pdf
Nemours Children's Hospital (Alfred I DuPont Hospital for Children)	Transplant	Wilmington	DE	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$122,000	30	Provisions the same as Inpatient	$3,100 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	95% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year post-Transplant		39.7299627	-75.5645038	371.pdf
Nemours Children's Hospital (Alfred I DuPont Hospital for Children)	Transplant	Wilmington	DE	Liver	Liver	Pediatric	Member's Choice		$176,000	19		$3,100 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	95% of Billed Charges			Included in Case Rate	N/A	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends One (1) Year post-Transplant		39.7299627	-75.5645038	372.pdf
Nemours Children's Hospital (Alfred I DuPont Hospital for Children)	Transplant	Wilmington	DE	Kidney	Kidney	Pediatric	Member's Choice		$75,000	15		$3,100 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	95% of Billed Charges			Included in Case Rate	N/A	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends One (1) Year post-Transplant		39.7299627	-75.5645038	373.pdf
Northside Hospital	Transplant	Atlanta	GA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceELITE	$135,000	90		$2,000 Med/Surg \| $2,000 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		33.7678358	-84.4906438	374.pdf
Northside Hospital	Transplant	Atlanta	GA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceELITE	$165,000	90		$2,000 Med/Surg \| $2,000 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		33.7678358	-84.4906438	374.pdf
Northside Hospital	Transplant	Atlanta	GA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceELITE	$90,000	50		$2,000 Med/Surg \| $2,000 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		33.7678358	-84.4906438	374.pdf
Northside Hospital	Transplant	Atlanta	GA	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Adult	Programs of Excellence	PerformanceELITE	$190,000	90 from 2nd Transplant		$2,000 Med/Surg \| $2,000 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		33.7678358	-84.4906438	374.pdf
Northside Hospital	Transplant	Atlanta	GA	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceELITE	$145,000	50 from 2nd Transplant		$2,000 Med/Surg \| $2,000 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		33.7678358	-84.4906438	374.pdf
Northside Hospital	Cellular Immunotherapy	Atlanta	GA	Cellular Immunotherapy	Cellular Immunotherapy				Charges $0 - $500,000 Pay at 60% \| Charges $500,001 - $1,000,000 Pay at 55% \| Charges $1,000,001 and Above Pay at 50% \| Drug Cost: 105% of Invoice Cost	N/A		N/A	N/A	60% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends 365 Days from Discharge		33.767693	-84.4908151	375.pdf
Northwest Marrow Transplant Program (Oregon Health & Science University /Legacy Good Samaritan Hospital and Medical Center)	Transplant	Portland	OR	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$174,417	N/A	65% of Billed Charges	N/A	87% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			If Billed Charges Exceed $317,439, Payment will be the Transplant Case Rate Plus 68% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	376.pdf
Northwest Marrow Transplant Program (Oregon Health & Science University /Legacy Good Samaritan Hospital and Medical Center)	Transplant	Portland	OR	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$236,023	N/A	65% of Billed Charges	N/A	87% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			If Billed Charges Exceed $429,562, Payment will be the Transplant Case Rate Plus 68% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	376.pdf
Northwest Marrow Transplant Program (Oregon Health & Science University /Legacy Good Samaritan Hospital and Medical Center)	Transplant	Portland	OR	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$252,321	N/A	65% of Billed Charges	N/A	87% of Billed Charges	70% of Billed Charges	Reimbursed at Invoice Cost Plus 5%	Reimbursed at 105% of Medicare D-6 Report			If Billed Charges Exceed $459,224, Payment will be the Transplant Case Rate Plus 68% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	376.pdf
Northwest Marrow Transplant Program (Oregon Health & Science University /Legacy Good Samaritan Hospital and Medical Center)	Transplant	Portland	OR	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Pediatric	Programs of Excellence		1st Infusion: $174,417 \| Any Additional Tandem: $137,092	N/A	65% of Billed Charges	N/A	87% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			If Billed Charges Exceed $317,439 for the 1st Infusion and $249,507 for the Any Additional Infusion, Payment will be the Transplant Case Rate Plus 68% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	376.pdf
Northwest Marrow Transplant Program (Oregon Health & Science University /Legacy Good Samaritan Hospital and Medical Center)	Transplant	Portland	OR	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	$150,582	N/A	65% of Billed Charges	N/A	87% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			If Billed Charges Exceed $274,059, Payment will be the Transplant Case Rate Plus 68% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	376.pdf
Northwest Marrow Transplant Program (Oregon Health & Science University /Legacy Good Samaritan Hospital and Medical Center)	Transplant	Portland	OR	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	$172,643	N/A	65% of Billed Charges	N/A	87% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			If Billed Charges Exceed $314,210, Payment will be the Transplant Case Rate Plus 68% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	376.pdf
Northwest Marrow Transplant Program (Oregon Health & Science University /Legacy Good Samaritan Hospital and Medical Center)	Transplant	Portland	OR	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	$156,874	N/A	65% of Billed Charges	N/A	87% of Billed Charges	70% of Billed Charges	Reimbursed at Invoice Cost Plus 5%	Reimbursed at Invoice Cost Plus 5%			If Billed Charges Exceed $285,511, Payment will be the Transplant Case Rate Plus 68% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	376.pdf
Northwest Marrow Transplant Program (Oregon Health & Science University /Legacy Good Samaritan Hospital and Medical Center)	Transplant	Portland	OR	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceSELECT	1st Infusion: $150,582 \| 2nd Infusion: $118,357	N/A	65% of Billed Charges	N/A	87% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			If Billed Charges Exceed $274,059 for the 1st Infusion and $215,411 for the 2nd Infusion, Payment will be the Transplant Case Rate Plus 68% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	376.pdf
Northwest Marrow Transplant Program (Oregon Health & Science University /Legacy Good Samaritan Hospital and Medical Center)	Transplant	Portland	OR	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Programs of Excellence	PerformanceSELECT	65% of Billed Charges	N/A	65% of Billed Charges	N/A	N/A	70% of Billed Charges	Reimbursed at Invoice Cost Plus 5%	N/A			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	376.pdf
Northwest Marrow Transplant Program (Oregon Health & Science University /Legacy Good Samaritan Hospital and Medical Center)	Transplant	Portland	OR	Blood/Marrow (Cord Blood)	Cord Blood	Pediatric	Programs of Excellence		65% of Billed Charges	N/A	65% of Billed Charges	N/A	N/A	70% of Billed Charges	Reimbursed at Invoice Cost Plus 5%	N/A			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	376.pdf
Northwestern Memorial Hospital	Transplant	Chicago	IL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$128,000	30		$2,500 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Invoice Cost + 5%			50% of Billed Charges	Begins at Evaluation	Beginning on Day One (1) of Ablative Therapy and Ending the Day of Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	377.pdf
Northwestern Memorial Hospital	Transplant	Chicago	IL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$148,000	40		$2,500 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Invoice Cost + 5%			50% of Billed Charges	Begins at Evaluation	Beginning on Day One (1) of Ablative Therapy and Ending the Day of Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	377.pdf
Northwestern Memorial Hospital	Transplant	Chicago	IL	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$90,000	25		$2,500 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Invoice Cost + 5%			50% of Billed Charges	Begins at Evaluation	Beginning on Day One (1) of Ablative Therapy and Ending the Day of Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	377.pdf
Northwestern Memorial Hospital	Transplant	Chicago	IL	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceQUALITY	1st: $90,000 \| 2nd: $75,000	25 \| 20		$2,500 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Invoice Cost + 5%			50% of Billed Charges	Begins at Evaluation	Beginning on Day One (1) of Ablative Therapy and Ending the Day of Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	377.pdf
Northwestern Memorial Hospital	Transplant	Chicago	IL	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Programs of Excellence	PerformanceQUALITY	$148,000	40		$2,500 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Invoice Cost + 5%			50% of Billed Charges	Begins at Evaluation	Beginning on Day One (1) of Ablative Therapy and Ending the Day of Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	377.pdf
Northwestern Memorial Hospital	Transplant	Chicago	IL	Heart	Heart	Adult	Programs of Excellence	PerformanceELITE	$240,000	23		$3,200 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Invoice Cost	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	378.pdf
Northwestern Memorial Hospital	Transplant	Chicago	IL	Intestine	Intestine	Adult	Member's Choice		65% of Billed Charges	N/A		N/A	N/A	75% of Billed Charges			Included in Case Rate	Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	379.pdf
Northwestern Memorial Hospital	Transplant	Chicago	IL	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor: $68,000 \| Living Donor: $66,000	12		$1,850 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Invoice Cost	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	380.pdf
Northwestern Memorial Hospital	Transplant	Chicago	IL	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceELITE	$130,000	22		$1,850 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Invoice Cost	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	381.pdf
Northwestern Memorial Hospital	Transplant	Chicago	IL	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor: $145,000 \| Living Donor: $155,000	25		$2,500 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Invoice Cost	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	382.pdf
Northwestern Memorial Hospital	Transplant	Chicago	IL	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	$235,000	25		$3,200 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Invoice Cost	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	383.pdf
Northwestern Memorial Hospital	Transplant	Chicago	IL	Pancreas	Pancreas	Adult	Programs of Excellence		$85,000	16		$1,850 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Invoice Cost	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	385.pdf
Northwestern Memorial Hospital	Cancer	Chicago	IL	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															41.8336474	-87.8723887	386.pdf
Ochsner Foundation Hospital	Transplant	Jefferson	LA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$125,000	30		$2,300 Med/Surg \| $3,300 ICU/CCU	80% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed 1.6 Times the Case Rate (Plus Applicable Per Diems), Payment will be the Transplant Case Rate, Plus 50% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.958954	-90.185577	387.pdf
Ochsner Foundation Hospital	Transplant	Jefferson	LA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$150,000	35		$2,300 Med/Surg \| $3,300 ICU/CCU	80% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed 1.6 Times the Case Rate (Plus Applicable Per Diems), Payment will be the Transplant Case Rate, Plus 50% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.958954	-90.185577	387.pdf
Ochsner Foundation Hospital	Transplant	Jefferson	LA	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$98,000	25		$2,300 Med/Surg \| $3,300 ICU/CCU	80% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed 1.6 Times the Case Rate (Plus Applicable Per Diems), Payment will be the Transplant Case Rate, Plus 50% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.958954	-90.185577	387.pdf
Ochsner Foundation Hospital	Transplant	Jefferson	LA	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Member's Choice		1st Transplant: $98,000 \| 2nd Transplant: $77,000	30 \| 20		$2,300 Med/Surg \| $3,300 ICU/CCU	80% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed 1.6 Times the Case Rate (Plus Applicable Per Diems), Payment will be the Transplant Case Rate, Plus 50% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.958954	-90.185577	387.pdf
Ochsner Foundation Hospital	Destination VAD	Jefferson	LA	Destination VAD	Destination VAD				Surgical Event: 75% of Billed Charges	N/A		Inpatient Per Diem: $7,500	Inpatient Services: Lesser of 80% of Billed Charges or $7,500 Per Diem	Outpatient Care: 75% of Billed Charges				75% of Billed Charges	55% of Billed Charges	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		29.9589168	-90.1856199	388.pdf
Ochsner Foundation Hospital	Transplant	Jefferson	LA	Heart	Heart	Adult	Member's Choice		$222,815	N/A		N/A	80% of Billed Charges	80% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed 1.6 Times the Case Rate (Plus Applicable Per Diems), Payment will be the Transplant Case Rate, Plus 50% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.958954	-90.185577	388.pdf
Ochsner Foundation Hospital	Transplant	Jefferson	LA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$105,098	N/A		N/A	80% of Billed Charges	80% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed 1.6 Times the Case Rate (Plus Applicable Per Diems), Payment will be the Transplant Case Rate, Plus 50% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.958954	-90.185577	389.pdf
Ochsner Foundation Hospital	Transplant	Jefferson	LA	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		$317,561	N/A		N/A	80% of Billed Charges	80% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed 1.6 Times the Case Rate (Plus Applicable Per Diems), Payment will be the Transplant Case Rate, Plus 50% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.958954	-90.185577	390.pdf
Ochsner Foundation Hospital	Transplant	Jefferson	LA	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	$173,902	N/A		N/A	80% of Billed Charges	80% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed 1.6 Times the Case Rate (Plus Applicable Per Diems), Payment will be the Transplant Case Rate, Plus 50% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.958954	-90.185577	391.pdf
Ochsner Foundation Hospital	Transplant	Jefferson	LA	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	$264,300	N/A		N/A	80% of Billed Charges	80% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed 1.6 Times the Case Rate (Plus Applicable Per Diems), Payment will be the Transplant Case Rate, Plus 50% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.958954	-90.185577	392.pdf
Ochsner Foundation Hospital	Transplant	Jefferson	LA	Multi-Organ	Multi-Organ	Adult	Member's Choice		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	N/A		N/A	80% of Billed Charges	80% of Billed Charges			Included in Case Rate	75% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.958954	-90.185577	393.pdf
Ochsner Foundation Hospital	Transplant	Jefferson	LA	Pancreas	Pancreas	Adult	Member's Choice		$136,098	N/A		N/A	80% of Billed Charges	80% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed 1.6 Times the Case Rate (Plus Applicable Per Diems), Payment will be the Transplant Case Rate, Plus 50% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.958954	-90.185577	394.pdf
Ochsner Foundation Hospital	Bariatric	Jefferson	LA	Bariatric	Bariatric				DRG 619 Hospital: $32,500 \| DRG 619 Professional: 70% of Billed Charges \| DRG 620 Hospital: $21,500 \| DRG 620 Professional: 70% of Billed Charges \| DRG 621 Hospital: $17,000 \| DRG 621 Professional: 70% of Billed Charges \| DRG 987 Hospital: $40,000 \| DRG 987 Professional: 70% of Billed Charges \| DRG 988 Hospital: $20,000 \| DRG 988 Professional: 70% of Billed Charges \| DRG 989 Hospital: $13,000 \| DRG 989 Professional: 70% of Billed Charges	DRG 619: 3 \| DRG 620: 3 \| DRG 621: 2 \| DRG 987: 3 \| DRG 988: 3 \| DRG 989: 2		$2,500	80% of Billed Charges	70% of Billed Charges					N/A	Begins at Evaluation	Begins on the Day of Surgery and Ends when the Number of Inlier Days and Applicable Outlier Days have Expired	Begins at Discharge and Ends One (1) Year Later		29.9589168	-90.1856199	396.pdf
Ochsner Foundation Hospital (Temporary Pause on Referrals)	Transplant	Jefferson	LA	Lung	Lung	Adult	Member's Choice		$250,917	N/A		N/A	80% of Billed Charges	80% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed 1.6 Times the Case Rate (Plus Applicable Per Diems), Payment will be the Transplant Case Rate, Plus 50% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.958954	-90.185577	395.pdf
Ohio State University Medical Center	Transplant	Columbus	OH	Pancreas	Pancreas	Adult	Programs of Excellence		$130,000	20		$3,000	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	65% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.9828667	-83.1312539	397.pdf
Ohio State University Medical Center	Transplant	Columbus	OH	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	$200,000	20		$3,000	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	65% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.9828667	-83.1312539	398.pdf
Ohio State University Medical Center	Transplant	Columbus	OH	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$230,000	25		$3,000	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	65% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.9828667	-83.1312539	399.pdf
Ohio State University Medical Center	Destination VAD	Columbus	OH	Destination VAD	Destination VAD				Surgical Event: 75% of Billed Charges	N/A		N/A	N/A	VAD Maintenance, Including Outpatient VAD Suppplies and Accessories: 65% of Billed Charges				65% of Billed Charges	N/A	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		39.9828667	-83.1312539	399.pdf
Ohio State University Medical Center	Transplant	Columbus	OH	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$115,000	10		$3,000	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	65% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.9828667	-83.1312539	400.pdf
Ohio State University Medical Center	Transplant	Columbus	OH	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	$210,000	20		$3,000	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	65% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.9828667	-83.1312539	401.pdf
Ohio State University Medical Center	Transplant	Columbus	OH	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	Single: $235,000 \| Bilateral: $270,000	30		$3,000	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	65% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.9828667	-83.1312539	402.pdf
Ohio State University Medical Center	Transplant	Columbus	OH	Heart/Lung	Heart/Lung	Adult	Member's Choice		$345,000	30		$3,000	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	65% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.9828667	-83.1312539	403.pdf
Ohio State University Medical Center	Transplant	Columbus	OH	Multi-Organ	Multi-Organ	Adult	Member's Choice		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	Equal to Number of Days of Higher Cost Organ		$3,000	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	65% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.9828667	-83.1312539	404.pdf
Oregon Health & Science University	Transplant	Portland	OR	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$328,219	N/A		N/A	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	Charges that Exceed $597,358 Shall be Reimbursed at 65% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	405.pdf
Oregon Health & Science University	Transplant	Portland	OR	Kidney	Kidney	Pediatric	Member's Choice		Cadaveric Donor: $123,688 \| Living Donor: $126,721	N/A		N/A	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	Cadaveric Donor: Charges that Exceed $225,112 Shall be Reimbursed at 65% of Billed Charges \| Living Donor: Charges that Exceed $230,632 Shall be Reimbursed at 65% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	406.pdf
Oregon Health & Science University	Transplant	Portland	OR	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor: $123,688 \| Living Donor: $126,721	N/A			90% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	Cadaveric Donor: Charges that Exceed $225,112 Shall be Reimbursed at 65% of Billed Charges \| Living Donor: Charges that Exceed $230,632 Shall be Reimbursed at 65% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	406.pdf
Oregon Health & Science University	Cellular Immunotherapy	Portland	OR	Cellular Immunotherapy	Cellular Immunotherapy				70% of Billed Charges \| Drug Cost: 105% of Wholesale Acquisition Cost (WAC)	N/A		N/A	N/A	70% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	407.pdf
Oregon Health & Science University	Transplant	Portland	OR	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	$228,534	N/A			90% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	Charges that Exceed $415,933 Shall be Reimbursed at 65% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	408.pdf
Oregon Health & Science University	Transplant	Portland	OR	Heart/Kidney	Heart/Kidney	Adult	Member's Choice			N/A		N/A	N/A	70% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for Gene Therapy Treatment	Begins on the First Day of Admission for Gene Therapy Treatment and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	882.pdf
Oregon Health & Science University	Transplant	Portland	OR	Liver/Heart	Liver/Heart	Adult	Member's Choice			N/A		N/A	N/A	70% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for Gene Therapy Treatment	Begins on the First Day of Admission for Gene Therapy Treatment and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	883.pdf
Oregon Health & Science University	Transplant	Portland	OR	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	$212,036	N/A			90% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	Charges that Exceed $385,905 Shall be Reimbursed at 65% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	409.pdf
Oregon Health & Science University	Bariatric	Portland	OR	Bariatric	Bariatric				Gastric Banding, Realize Band, Lap-Band: $19,209 \| Gastric Bypass, Biliopancreatic Bypass: $31,434 \| Gastric Sleeve: $19,501 \| Duodenal Switch: $34,345 \| Professional: 75% of Billed Charges	Gastric Banding, Realize Band, Lap-Band: 2 \| Gastric Bypass, Biliopancreatic Bypass: 3 \| Gastric Sleeve: 2 \| Duodenal Switch: 3		Hospital: $5,646 \| Professional: 75% of Billed Charges	90% of Billed Charges	Hospital: 70% of Billed Charges \| Professional: 75% of Billed Charges					55% of Billed Charges	Begins at Evaluation	Begins on the Day of Surgery and Ends when the Number of Inlier Days and Applicable Outlier Days have Expired	Begins at Discharge and Ends One (1) Year Later		45.5426915	-122.7245379	410.pdf
Oregon Health & Science University	Destination VAD	Portland	OR	Destination VAD	Destination VAD				Surgical Event Hospital: $418,080 \| Surgical Event Professional: 70% of Billed Charges	N/A		N/A	90% of Billed Charges	70% of Billed Charges				Included in the Hospital Case Rate	Charges that Exceed 180% ($752,544) of the Applicable Surgical Event Case Rate (Hospital), Shall be Reimbursed at 75% of Billed Charges	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		45.5426915	-122.7245379	411.pdf
Oregon Health & Science University	Cancer	Portland	OR	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															45.5426915	-122.7245379	412.pdf
Oregon Health & Science University	Transplant	Portland	OR	Heart	Heart	Adult	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A		N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges			200% of Medicare Cost Report	100% of Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	415.pdf
Oregon Health & Science University	Transplant	Portland	OR	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A		N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges			200% of Medicare Cost Report	100% of Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	415.pdf
Oregon Health & Science University	Transplant	Portland	OR	Liver	Liver	Adult	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A		N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges			200% of Medicare Cost Report	100% of Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	415.pdf
Oregon Health & Science University	Transplant	Portland	OR	Pancreas	Pancreas	Adult	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A		N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges			200% of Medicare Cost Report	100% of Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	415.pdf
Oregon Health & Science University	Transplant	Portland	OR	Kidney	Kidney	Adult	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A		N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges			200% of Medicare Cost Report	100% of Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	415.pdf
Oregon Health & Science University	Transplant	Portland	OR	Blood/Marrow (Autologous)	Autologous	Pediatric	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A	N/A	N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	100% of Invoice Cost	N/A			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	416.pdf
Oregon Health & Science University	Transplant	Portland	OR	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A	N/A	N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	100% of Invoice Cost	N/A			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	416.pdf
Oregon Health & Science University	Transplant	Portland	OR	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A	N/A	N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	100% of Invoice Cost	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	416.pdf
Oregon Health & Science University	Transplant	Portland	OR	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A	N/A	N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	100% of Invoice Cost	N/A			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	416.pdf
Oregon Health & Science University	Transplant	Portland	OR	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A	N/A	N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	100% of Invoice Cost	N/A			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	416.pdf
Oregon Health & Science University	Transplant	Portland	OR	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A	N/A	N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	100% of Invoice Cost	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	416.pdf
Oregon Health & Science University	Transplant	Portland	OR	Blood/Marrow (Tandem)	Tandem Auto to Auto	Adult	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A	N/A	N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	100% of Invoice Cost	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	416.pdf
Oregon Health & Science University (Applies to OEBB/PEBB Only)	Transplant	Portland	OR	Heart	Heart	Adult	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A		N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges			200% of Medicare Cost Report	100% of Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	413.pdf
Oregon Health & Science University (Applies to OEBB/PEBB Only)	Transplant	Portland	OR	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A		N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges			200% of Medicare Cost Report	100% of Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	413.pdf
Oregon Health & Science University (Applies to OEBB/PEBB Only)	Transplant	Portland	OR	Liver	Liver	Adult	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A		N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges			200% of Medicare Cost Report	100% of Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	413.pdf
Oregon Health & Science University (Applies to OEBB/PEBB Only)	Transplant	Portland	OR	Pancreas	Pancreas	Adult	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A		N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges			200% of Medicare Cost Report	100% of Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	413.pdf
Oregon Health & Science University (Applies to OEBB/PEBB Only)	Transplant	Portland	OR	Kidney	Kidney	Adult	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A		N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges			200% of Medicare Cost Report	100% of Invoice Cost	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	413.pdf
Oregon Health & Science University (Applies to OEBB/PEBB Only)	Transplant	Portland	OR	Blood/Marrow (Autologous)	Autologous	Pediatric	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A	N/A	N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	100% of Invoice Cost	N/A			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	414.pdf
Oregon Health & Science University (Applies to OEBB/PEBB Only)	Transplant	Portland	OR	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A	N/A	N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	100% of Invoice Cost	N/A			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	414.pdf
Oregon Health & Science University (Applies to OEBB/PEBB Only)	Transplant	Portland	OR	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A	N/A	N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	100% of Invoice Cost	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	414.pdf
Oregon Health & Science University (Applies to OEBB/PEBB Only)	Transplant	Portland	OR	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A	N/A	N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	100% of Invoice Cost	N/A			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	414.pdf
Oregon Health & Science University (Applies to OEBB/PEBB Only)	Transplant	Portland	OR	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A	N/A	N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	100% of Invoice Cost	N/A			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	414.pdf
Oregon Health & Science University (Applies to OEBB/PEBB Only)	Transplant	Portland	OR	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A	N/A	N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	100% of Invoice Cost	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	414.pdf
Oregon Health & Science University (Applies to OEBB/PEBB Only)	Transplant	Portland	OR	Blood/Marrow (Tandem)	Tandem Auto to Auto	Adult	Government Rates		Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	N/A	N/A	N/A	N/A	Hospital: 200% of Medicare Fee Schedule \| Professional: 70% of Billed Charges	100% of Invoice Cost	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		45.5426915	-122.7245379	414.pdf
Oregon Health & Science University (Gene Therapy)	Cellular Immunotherapy	Portland	OR	Cellular Immunotherapy	Gene Therapy				70% of Billed Charges \| Drug Cost: 105% of Wholesale Acquisition Cost (WAC)	N/A		N/A	N/A	70% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for Gene Therapy Treatment	Begins on the First Day of Admission for Gene Therapy Treatment and Ends at Discharge	Ends One (1) Year from Discharge		45.5426915	-122.7245379	868.pdf
Phoenix Children's Hospital	Transplant	Phoenix	AZ	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$180,000	30	N/A	$6,000 Med/Surg	90% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Any Charges that Exceed $350,000 Shall be Reimbursed at 65%, in Addition to the Case Rate and any Applicable Per Diems	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from the End of the Inlier Days and any Applicable Outlier Days		33.6056711	-112.4052341	419.pdf
Phoenix Children's Hospital	Transplant	Phoenix	AZ	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$200,000	35	N/A	$6,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Any Charges that Exceed $380,000 Shall be Reimbursed at 65%, in Addition to the Case Rate and any Applicable Per Diems	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from the End of the Inlier Days and any Applicable Outlier Days		33.6056711	-112.4052341	419.pdf
Phoenix Children's Hospital	Transplant	Phoenix	AZ	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$150,000	25	N/A	$6,000 Med/Surg \| $6,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Any Charges that Exceed $280,000 Shall be Reimbursed at 65%, in Addition to the Case Rate and any Applicable Per Diems	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from the End of the Inlier Days and any Applicable Outlier Days		33.6056711	-112.4052341	419.pdf
Phoenix Children's Hospital	Transplant	Phoenix	AZ	Blood/Marrow (Tandem)	Tandem Auto to Auto	Pediatric	Programs of Excellence		1st Transplant: $150,000 \| 2nd Transplant: $140,000	25		$6,000 Med/Surg \| $6,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Any Charges that Exceed $280,000 for the 1st Transplant and $260,000 for the 2nd Transplant Shall be Reimbursed at 65%, in Addition to the Case Rate and any Applicable Per Diems	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		33.6050976	-112.4059148	419.pdf
Phoenix Children's Hospital	Transplant	Phoenix	AZ	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Pediatric	Programs of Excellence		1st Transplant: $150,000 \| 2nd Transplant: $185,000	25		$6,000 Med/Surg \| $6,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Any Charges that Exceed $280,000 for the 1st Transplant and $260,000 for the 2nd Transplant Shall be Reimbursed at 65%, in Addition to the Case Rate and any Applicable Per Diems	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		33.6050976	-112.4059148	419.pdf
Phoenix Children's Hospital	Transplant	Phoenix	AZ	Heart	Heart	Pediatric	Programs of Excellence		$300,000	15		$6,000 Med/Surg \| $6,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost, Plus 10%	Any Charges that Exceed $520,000 Shall be Reimbursed at 65%, in Addition to the Case Rate and any Applicable Per Diems	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends Upon the Expiration of the Inlier Days or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		33.6056711	-112.4052341	420.pdf
Phoenix Children's Hospital	Transplant	Phoenix	AZ	Kidney	Kidney	Pediatric	Programs of Excellence		Cadaveric Donor: $130,000 \| Living Donor: $140,000	Cadaveric: 9 \|Living: 10		$6,000 Med/Surg \| $6,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost, Plus 10%	Any Charges that Exceed $240,000 (Cadaveric) or $260,000 (Living) Shall be Reimbursed at 65%, in Addition to the Case Rate and any Applicable Per Diems	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends Upon the Expiration of the Inlier Days or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		33.6056711	-112.4052341	421.pdf
Phoenix Children's Hospital	Transplant	Phoenix	AZ	Liver	Liver	Pediatric	Member's Choice		$225,000	30		$6,000 Med/Surg \| $6,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost, Plus 10%	Any Charges that Exceed $420,000 Shall be Reimbursed at 65%, in Addition to the Case Rate and any Applicable Per Diems	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends Upon the Expiration of the Inlier Days or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		33.6056711	-112.4052341	422.pdf
Phoenix Children's Hospital	Congenital Heart Defect	Phoenix	AZ	Congenital Heart Defect	Congenital Heart Defect				Inpatient & Outpatient Services: 70% of Billed Charges	N/A		N/A	N/A	Inpatient & Outpatient Services: 70% of Billed Charges				110% of Invoice Cost	N/A	Begins on the Date of Referral to INTERLINK	Begins Upon Referral to INTERLINK &/Or when Patient is Admitted to Facility	Coverage Remains Active Until Patient No Longer Requires Pediatric Heart Services		33.6050976	-112.4059148	423.pdf
Providence Sacred Heart Medical Center	Transplant	Spokane	WA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$110,000	6		$4,000 Med/Surg \| $5,500 ICU/CCU	75% of Billed Charges	75% of Billed Charges			100% of Provider's Current Medicare Cost Report for Organ Acquisition	75% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		47.6729347	-117.4821894	424.pdf
Providence St. Vincent Medical Center	Destination VAD	Oregon	OR	Destination VAD	Destination VAD				105% of Medicare Fee Schedule			N/A	N/A	105% of Medicare Fee Schedule				100% of Invoice Cost	N/A	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		45.5426915	-122.7245379	425.pdf
Providence St. Vincent Medical Center	Transplant	Oregon	OR	Heart	Heart	Adult	Government Rates		105% of Medicare Fee Schedule			N/A	N/A	105% of Medicare Fee Schedule			Reimbursed Based on Most Current Available Medicare Cost Report Worksheet D-4 Using the Following Calculation: Total Cost Minus Revenue for Organ Sold Divided by Total Usable Organs		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends Upon the Expiration of the Inlier Days or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		45.5426915	-122.7245379	425.pdf
Providence St. Vincent Medical Center	Destination VAD	Oregon	OR	Destination VAD	Destination VAD				Surgical Event: 70% of Billed Charges			N/A	N/A	70% of Billed Charges \| VAD Maintenance & Supplies: 70% of Billed Charges				100% of Invoice Cost	N/A	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		45.5426915	-122.7245379	426.pdf
Providence St. Vincent Medical Center	Transplant	Oregon	OR	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$656,000	24		$3,000 Med/Surg \| $4,500 ICU/CCU	70% of Billed Charges	70% of Billed Charges			Included in Case Rate			Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends Upon the Expiration of the Inlier Days or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		45.5426915	-122.7245379	426.pdf
Rady Children's Hospital and Health Center	Transplant	Encinitas	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$160,000	35	Provisions the same as Inpatient	65% of Billed Charges	85% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		33.0441071	-117.2892539	427.pdf
Rady Children's Hospital and Health Center	Transplant	Encinitas	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$225,000	40	Provisions the same as Inpatient	65% of Billed Charges	85% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		33.0441071	-117.2892539	427.pdf
Rady Children's Hospital and Health Center	Transplant	Encinitas	CA	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$120,000	30	Provisions the same as Inpatient	65% of Billed Charges	85% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		33.0441071	-117.2892539	427.pdf
Rady Children's Hospital and Health Center	Transplant	Encinitas	CA	Blood/Marrow (Tandem)	Tandem Auto to Auto	Pediatric	Programs of Excellence		1st Transplant: $120,000 \| 2nd & 3rd Transplant: 80% of 1st Transplant Case Rate	30 for Each Transplant		65% of Billed Charges	85% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends (1) Year from Discharge		33.0441071	-117.2892539	427.pdf
Rady Children's Hospital and Health Center	Transplant	Encinitas	CA	Blood/Marrow (Cord Blood)	Cord Blood	Pediatric	Programs of Excellence		$240,000	40		65% of Billed Charges	85% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends (1) Year from Discharge		33.0441071	-117.2892539	427.pdf
Rady Children's Hospital and Health Center	Transplant	Encinitas	CA	Kidney	Kidney	Pediatric	Programs of Excellence		$90,000	15		65% of Billed Charges	85% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends 365 Days from Discharge		33.0441071	-117.2892539	428.pdf
Rady Children's Hospital and Health Center	Transplant	Encinitas	CA	Liver	Liver	Pediatric	Member's Choice		$200,000	25		65% of Billed Charges	85% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends 365 Days from Discharge		33.0441071	-117.2892539	429.pdf
Scripps Green Hospital	Transplant	San Diego	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$125,000	N/A		N/A	65% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Any Charges that Exceed $312,500 in Billed Charges Shall be Reimbursed at 70% of Billed Charges in Addition to the Case Rate	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		32.8248175	-117.3891618	449.pdf
Scripps Green Hospital	Transplant	San Diego	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$140,000	N/A		N/A	65% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Any Charges that Exceed $350,000 in Billed Charges Shall be Reimbursed at 70% of Billed Charges in Addition to the Case Rate	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		32.8248175	-117.3891618	449.pdf
Scripps Green Hospital	Transplant	San Diego	CA	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$80,000	N/A		N/A	65% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Any Charges that Exceed $200,000 in Billed Charges Shall be Reimbursed at 70% of Billed Charges in Addition to the Case Rate	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		32.8248175	-117.3891618	449.pdf
Scripps Green Hospital	Transplant	San Diego	CA	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Member's Choice		1st Transplant: $80,000 \| 2nd Transplant: $60,000	N/A		N/A	65% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Any Charges that Exceed $350,000 in Billed Charges Shall be Reimbursed at 70% of Billed Charges in Addition to the Case Rate	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		32.8248175	-117.3891618	449.pdf
Scripps Green Hospital	Transplant	San Diego	CA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor: $55,000: \| Living Donor: $75,000	N/A		N/A	65% of Billed Charges	70% of Billed Charges			Cadaveric Donor: Reimbursed at Invoice Cost \| Living Donor: Included in Case Rate	N/A	Any Charges that Exceed $162,500 (Cadaveric) or $195,000 (Living), Shall be Reimbursed at 70% of Billed Charges in Addition to the Case Rate	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		32.8248175	-117.3891618	450.pdf
Scripps Green Hospital	Transplant	San Diego	CA	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$80,000	N/A		N/A	65% of Billed Charges	70% of Billed Charges			Donor Charges Reimbursed at Invoice Cost	N/A	Any Charges that Exceed $212,500 will be Reimbursed at 70% of Billed Charges in Addition to the Case Rate	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		32.8248175	-117.3891618	451.pdf
Scripps Green Hospital	Transplant	San Diego	CA	Liver	Liver	Adult	Member's Choice		Cadaveric Donor: $120,000 \| Living Donor: $160,000	N/A		N/A	65% of Billed Charges	70% of Billed Charges			Cadaveric Donor: Reimbursed at Invoice Cost \| Living Donor: Included in Case Rate	N/A	Any Charges that Exceed $312,500 (Cadaveric) or $400,000 (Living), will be Reimbursed at 70% of Billed Charges in Addition to the Case Rate	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		32.8248175	-117.3891618	452.pdf
Scripps Green Hospital	Transplant	San Diego	CA	Pancreas	Pancreas	Adult	Programs of Excellence		$70,000	N/A		N/A	65% of Billed Charges	70% of Billed Charges			Donor Charges Reimbursed at Invoice Cost	N/A	Any Charges that Exceed $187,500 will be Reimbursed at 70% of Billed Charges in Addition to the Case Rate	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		32.8248175	-117.3891618	453.pdf
Scripps Green Hospital	Transplant	San Diego	CA	Cellular Immunotherapy	Cellular Immunotherapy	Adult	Programs of Excellence		$70,000	N/A		N/A	65% of Billed Charges	70% of Billed Charges			Donor Charges Reimbursed at Invoice Cost	N/A	Any Charges that Exceed $187,500 will be Reimbursed at 70% of Billed Charges in Addition to the Case Rate	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		32.8248175	-117.3891618	885.pdf
Scripps Green Hospital	Transplant	San Diego	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates		175% of Medicare Allowable	N/A		N/A	100% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Any Charges that Exceed $312,500 in Billed Charges Shall be Reimbursed at 70% of Billed Charges in Addition to the Case Rate	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		32.8248175	-117.3891618	886.pdf
Scripps Green Hospital	Transplant	San Diego	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Government Rates		175% of Medicare Allowable	N/A		N/A	100% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Any Charges that Exceed $350,000 in Billed Charges Shall be Reimbursed at 70% of Billed Charges in Addition to the Case Rate	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		32.8248175	-117.3891618	886.pdf
Scripps Green Hospital	Transplant	San Diego	CA	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates		175% of Medicare Allowable	N/A		N/A	100% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Any Charges that Exceed $200,000 in Billed Charges Shall be Reimbursed at 70% of Billed Charges in Addition to the Case Rate	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		32.8248175	-117.3891618	886.pdf
Scripps Green Hospital	Transplant	San Diego	CA	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Government Rates		175% of Medicare Allowable	N/A		N/A	100% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			Any Charges that Exceed $350,000 in Billed Charges Shall be Reimbursed at 70% of Billed Charges in Addition to the Case Rate	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		32.8248175	-117.3891618	886.pdf
Scripps Green Hospital	Transplant	San Diego	CA	Kidney	Kidney	Adult	Government Rates		175% of Medicare Allowable	N/A		N/A	100% of Billed Charges	70% of Billed Charges			Cadaveric Donor: Reimbursed at Invoice Cost \| Living Donor: Included in Case Rate	N/A	Any Charges that Exceed $162,500 (Cadaveric) or $195,000 (Living), Shall be Reimbursed at 70% of Billed Charges in Addition to the Case Rate	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		32.8248175	-117.3891618	887.pdf
Scripps Green Hospital	Transplant	San Diego	CA	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates		175% of Medicare Allowable	N/A		N/A	100% of Billed Charges	70% of Billed Charges			Donor Charges Reimbursed at Invoice Cost	N/A	Any Charges that Exceed $212,500 will be Reimbursed at 70% of Billed Charges in Addition to the Case Rate	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		32.8248175	-117.3891618	887.pdf
Scripps Green Hospital	Transplant	San Diego	CA	Liver	Liver	Adult	Government Rates		175% of Medicare Allowable	N/A		N/A	100% of Billed Charges	70% of Billed Charges			Cadaveric Donor: Reimbursed at Invoice Cost \| Living Donor: Included in Case Rate	N/A	Any Charges that Exceed $312,500 (Cadaveric) or $400,000 (Living), will be Reimbursed at 70% of Billed Charges in Addition to the Case Rate	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		32.8248175	-117.3891618	887.pdf
Scripps Green Hospital	Transplant	San Diego	CA	Pancreas	Pancreas	Adult	Government Rates		175% of Medicare Allowable	N/A		N/A	100% of Billed Charges	70% of Billed Charges			Donor Charges Reimbursed at Invoice Cost	N/A	Any Charges that Exceed $187,500 will be Reimbursed at 70% of Billed Charges in Addition to the Case Rate	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		32.8248175	-117.3891618	887.pdf
Seattle Children's Hospital	Cellular Immunotherapy	Seattle	WA	Cellular Immunotherapy	Cellular Immunotherapy				80% of Billed Charges \| Drug Cost: 110% of Wholesale Acquisition Cost (WAC)	N/A		N/A	N/A	80% of Billed Charges					N/A	Begins at Evaluation	Begins On Day of Admission for CAR T-Cell Therapy and Ends at Discharge	Ends One (1) Year from Discharge		47.603832	-122.330062	454.pdf
Seattle Children's Hospital	Transplant	Seattle	WA	Heart	Heart	Pediatric	Programs of Excellence		Hospital: $261,085 \| Professional: $63,609	N/A		N/A	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	Reimbursed at 85% of Billed Charges	75% of Billed Charges	Begins at Evaluation	Begins On the Day of Transplantation and Ends at Discharge	Ends 90 Days from Discharge		47.613007	-122.4122753	455.pdf
Seattle Children's Hospital	Transplant	Seattle	WA	Kidney	Kidney	Pediatric	Programs of Excellence		Cadaveric Donor: Hospital: $109,854 \| Professional: $27,074 \| Living Donor: Hospital: $111,470 \| Professional: $27,233	N/A		N/A	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	Reimbursed at 85% of Billed Charges	75% of Billed Charges	Begins at Evaluation	Begins On the Day of Transplantation and Ends at Discharge	Ends 90 Days from Discharge		47.613007	-122.4122753	457.pdf
Seattle Children's Hospital	Transplant	Seattle	WA	Liver	Liver	Pediatric	Programs of Excellence		Cadaveric Donor Hospital: $254,186 \| Cadaveric Donor Professional: $60,341 \| Living Donor Hospital: $254,186 \| Living Donor Professional: $61,507	N/A		N/A	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	Reimbursed at 85% of Billed Charges	75% of Billed Charges	Begins at Evaluation	Begins On the Day of Transplantation and Ends at Discharge	Ends 90 Days from Discharge		47.613007	-122.4122753	458.pdf
Seattle Children's Hospital (Applies to In-State or Out-of-State Managed Medicaid or Medicare Advantage Only)	Transplant	Seattle	WA	Heart	Heart	Pediatric	Government Rates		65% of Billed Charges	N/A	N/A	N/A	N/A	65% of Billed Charges			65% of Billed Charges		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 90 Days from Discharge		47.603832	-122.330062	459.pdf
Seattle Children's Hospital (Applies to In-State or Out-of-State Managed Medicaid or Medicare Advantage Only)	Transplant	Seattle	WA	Kidney	Kidney	Pediatric	Government Rates		65% of Billed Charges	N/A	N/A	N/A	N/A	65% of Billed Charges			65% of Billed Charges		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 90 Days from Discharge		47.603832	-122.330062	459.pdf
Seattle Children's Hospital (Applies to In-State or Out-of-State Managed Medicaid or Medicare Advantage Only)	Transplant	Seattle	WA	Liver	Liver	Pediatric	Government Rates		65% of Billed Charges	N/A	N/A	N/A	N/A	65% of Billed Charges			65% of Billed Charges		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 90 Days from Discharge		47.603832	-122.330062	459.pdf
SSM Health Saint Louis University Hospital	Transplant	St Louis	MO	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$135,000	30		$2,700 Med/Surg \| $3,200 ICU/CCU	75% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		38.653285	-90.3835452	460.pdf
SSM Health Saint Louis University Hospital	Transplant	St Louis	MO	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$175,000	40		$2,700 Med/Surg \| $3,200 ICU/CCU	75% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		38.653285	-90.3835452	460.pdf
SSM Health Saint Louis University Hospital	Transplant	St Louis	MO	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$85,000	22		$2,700 Med/Surg \| $3,200 ICU/CCU	75% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		38.653285	-90.3835452	460.pdf
SSM Health Saint Louis University Hospital	Transplant	St Louis	MO	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		$170,000	20		$2,700 Med/Surg \| $3,200 ICU/CCU	75% of Billed Charges	70% of Billed Charges			Included in Case Rate if Organ was Procured within the UNOS Region of this Hospital, Otherwise, Reimbursed at Invoice Cost		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		38.653285	-90.3835452	461.pdf
SSM Health Saint Louis University Hospital	Transplant	St Louis	MO	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$120,000	20		$2,700 Med/Surg \| $3,200 ICU/CCU	75% of Billed Charges	70% of Billed Charges			Included in Case Rate if Organ was Procured within the UNOS Region of this Hospital, Otherwise, Reimbursed at Invoice Cost		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		38.653285	-90.3835452	462.pdf
SSM Health Saint Louis University Hospital	Transplant	St Louis	MO	Liver	Liver	Adult	Member's Choice		$130,000	13		$2,700 Med/Surg \| $3,200 ICU/CCU	75% of Billed Charges	70% of Billed Charges			Included in Case Rate if Organ was Procured within the UNOS Region of this Hospital, Otherwise, Reimbursed at Invoice Cost		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		38.653285	-90.3835452	463.pdf
SSM Health Saint Louis University Hospital	Transplant	St Louis	MO	Pancreas	Pancreas	Adult	Programs of Excellence		$92,000	18		$2,700 Med/Surg \| $3,200 ICU/CCU	75% of Billed Charges	70% of Billed Charges			Included in Case Rate if Organ was Procured within the UNOS Region of this Hospital, Otherwise, Reimbursed at Invoice Cost		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		38.653285	-90.3835452	464.pdf
SSM Health Saint Louis University Hospital	Transplant	St Louis	MO	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$64,000	8		$2,700 Med/Surg \| $3,200 ICU/CCU	75% of Billed Charges	70% of Billed Charges			Included in Case Rate if Organ was Procured within the UNOS Region of this Hospital, Otherwise, Reimbursed at Invoice Cost		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		38.653285	-90.3835452	465.pdf
SSM Health Saint Louis University Hospital (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	St Louis	MO	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates		Hospital and Professional Services: 115% of Medicare Allowable amounts current on the date services were rendered.					Hospital and Professional Services: 115% of Medicare Allowable amounts current on the date services were rendered.	Included in the Case Rate	Included in the Case Rate				Begins at Evaluation	Begins on the day of Admission for Ablative Therapy	Ends One (1) Year from Discharge		38.628028	-90.191015	466.pdf
SSM Health Saint Louis University Hospital (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	St Louis	MO	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Government Rates		Hospital and Professional Services: 115% of Medicare Allowable amounts current on the date services were rendered.					Hospital and Professional Services: 115% of Medicare Allowable amounts current on the date services were rendered.	Included in the Case Rate	Included in the Case Rate				Begins at Evaluation	Begins on the day of Admission for Ablative Therapy	Ends One (1) Year from Discharge		38.628028	-90.191015	467.pdf
SSM Health Saint Louis University Hospital (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	St Louis	MO	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Government Rates		Hospital and Professional Services: 115% of Medicare Allowable amounts current on the date services were rendered.					Hospital and Professional Services: 115% of Medicare Allowable amounts current on the date services were rendered.	Included in the Case Rate	Included in the Case Rate				Begins at Evaluation	Begins on the day of Admission for Ablative Therapy	Ends One (1) Year from Discharge		38.628028	-90.191015	467.pdf
SSM Health Saint Louis University Hospital (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	St Louis	MO	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates		Hospital and Professional Services: 115% of Medicare Allowable amounts current on the date services were rendered.					Hospital and Professional Services: 115% of Medicare Allowable amounts current on the date services were rendered.	Included in the Case Rate	Included in the Case Rate				Begins at Evaluation	Begins on the day of Admission for Ablative Therapy	Ends One (1) Year from Discharge		38.628028	-90.191015	467.pdf
SSM Health Saint Louis University Hospital (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	St Louis	MO	Kidney/Liver	Kidney/Liver	Adult	Government Rates		Hospital and Professional Services: 115% of Medicare Allowable amounts current on the date services were rendered.					Hospital and Professional Services: 115% of Medicare Allowable amounts current on the date services were rendered.			100% of the Organ Procurement Organization Invoice Cost			Begins at Evaluation	Begins on the day of Admission for Transplantation	Ends One (1) Year from Discharge		38.628028	-90.191015	468.pdf
SSM Health Saint Louis University Hospital (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	St Louis	MO	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates		Hospital and Professional Services: 115% of Medicare Allowable amounts current on the date services were rendered.					Hospital and Professional Services: 115% of Medicare Allowable amounts current on the date services were rendered.			100% of the Organ Procurement Organization Invoice Cost			Begins at Evaluation	Begins on the day of Admission for Transplantation	Ends One (1) Year from Discharge		38.628028	-90.191015	468.pdf
SSM Health Saint Louis University Hospital (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	St Louis	MO	Liver	Liver	Adult	Government Rates		Hospital and Professional Services: 115% of Medicare Allowable amounts current on the date services were rendered.					Hospital and Professional Services: 115% of Medicare Allowable amounts current on the date services were rendered.			100% of the Organ Procurement Organization Invoice Cost			Begins at Evaluation	Begins on the day of Admission for Transplantation	Ends One (1) Year from Discharge		38.628028	-90.191015	468.pdf
SSM Health Saint Louis University Hospital (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	St Louis	MO	Pancreas	Pancreas	Adult	Government Rates		Hospital and Professional Services: 115% of Medicare Allowable amounts current on the date services were rendered.					Hospital and Professional Services: 115% of Medicare Allowable amounts current on the date services were rendered.			100% of the Organ Procurement Organization Invoice Cost			Begins at Evaluation	Begins on the day of Admission for Transplantation	Ends One (1) Year from Discharge		38.628028	-90.191015	468.pdf
SSM Health Saint Louis University Hospital (Applies to Managed Medicaid and Medicare Advantage Patients Only)	Transplant	St Louis	MO	Kidney	Kidney	Adult	Government Rates		Hospital and Professional Services: 115% of Medicare Allowable amounts current on the date services were rendered.					Hospital and Professional Services: 115% of Medicare Allowable amounts current on the date services were rendered.			100% of the Organ Procurement Organization Invoice Cost			Begins at Evaluation	Begins on the day of Admission for Transplantation	Ends One (1) Year from Discharge		38.628028	-90.191015	468.pdf
St Joseph's Hospital and Medical Center	Transplant	Phoenix	AZ	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $85,000 \| Professonal: $15,000	7		Hospital: $4,500 \| Professional: $950	90% of Billed Charges	Hospital Inpatient: $4,500 Per Diem \| Hospital Outpatient: 70% of Billed Charges \| Professional Inpatient: $950 Per Diem \| Professional Outpatient: 70% of Billed Charges \| Acute Rehab: 70% of Billed Charges			Included in Case Rate	Reimbursed at 120% of Invoice Cost	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		33.6056711	-112.4052341	469.pdf
St Joseph's Hospital and Medical Center	Transplant	Phoenix	AZ	Liver	Liver	Adult	Member's Choice		Hospital: $190,000 \| Professonal: $33,000	20		Hospital: $4,500 \| Professional: $950	90% of Billed Charges	Hospital Inpatient: $4,500 Per Diem \| Hospital Outpatient: 70% of Billed Charges \| Professional Inpatient: $950 Per Diem \|Professional Outpatient: 70% of Billed Charges \| Acute Rehab: 70% of Billed Charges			Included in Case Rate	Reimbursed at 120% of Invoice Cost	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		33.6056711	-112.4052341	470.pdf
St Joseph's Hospital and Medical Center	Transplant	Phoenix	AZ	Lung	Lung	Adult	Programs of Excellence	PerformanceELITE	Hospital: $248,000 \| Professonal: $39,000	20		Hospital: $4,500 \| Professional: $950	90% of Billed Charges	Hospital Inpatient: $4,500 Per Diem \| Hospital Outpatient: 70% of Billed Charges \| Professional Inpatient: $950 Per Diem \| Professional Outpatient: 70% of Billed Charges \| Acute Rehab: 70% of Billed Charges			Included in Case Rate	Reimbursed at 120% of Invoice Cost	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		33.6056711	-112.4052341	471.pdf
St Joseph's Hospital and Medical Center	Transplant	Phoenix	AZ	Multi-Organ	Multi-Organ	Adult	Member's Choice		100% of Higher Cost Organ + 70% of Lower Cost Organ	20		Hospital: $4,500 \| Professional: $950		Hospital Inpatient: $4,500 Per Diem \| Hospital Outpatient: 70% of Billed Charges \| Professional Inpatient: $950 Per Diem \| Professional Outpatient: 70% of Billed Charges			Included in Case Rate	Reimbursed at 120% of Invoice Cost	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		33.6056711	-112.4052341	472.pdf
St Jude Children's Research Hospital	Transplant	Memphis	TN	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$138,000	35		$2,916 Med/Surg \| $3,240 ICU/CCU	90% of Billed Charges	Inpatient Hospital: $2,916 (Med/Surg), $3,240 (ICU/CCU) \| All Other: 75% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		35.129105	-90.1112123	473.pdf
St Jude Children's Research Hospital	Transplant	Memphis	TN	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$192,000	35		$2,916 Med/Surg \| $3,240 ICU/CCU	90% of Billed Charges	Inpatient Hospital: $2,916 (Med/Surg), $3,240 (ICU/CCU) \| All Other: 75% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		35.129105	-90.1112123	473.pdf
St Jude Children's Research Hospital	Transplant	Memphis	TN	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$222,000	35		$2,916 Med/Surg \| $3,240 ICU/CCU	90% of Billed Charges	Inpatient Hospital: $2,916 (Med/Surg), $3,240 (ICU/CCU) \| All Other: 75% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		35.129105	-90.1112123	473.pdf
St Jude Children's Research Hospital	Transplant	Memphis	TN	Blood/Marrow (Tandem)	Tandem Auto to Allo	Pediatric	Programs of Excellence		65% of Billed Charges	N/A		N/A	90% of Billed Charges	Inpatient Hospital: $2,916 (Med/Surg), $3,240 (ICU/CCU) \| All Other: 75% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		35.129105	-90.1112123	473.pdf
St Jude Children's Research Hospital	Transplant	Memphis	TN	Blood/Marrow (Tandem)	Tandem Auto to Auto	Pediatric	Programs of Excellence		65% of Billed Charges	N/A		N/A	90% of Billed Charges	Inpatient Hospital: $2,916 (Med/Surg), $3,240 (ICU/CCU) \| All Other: 75% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		35.129105	-90.1112123	473.pdf
St Jude Children's Research Hospital	Cancer	Memphis	TN	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															35.129105	-90.1112123	474.pdf
St Louis Children's Hospital	Transplant	St Louis	MO	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$105,000	N/A		N/A	N/A	80% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed $139,650, Payment will be the Transplant Case Rate, Plus 75% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		38.653285	-90.3835452	475.pdf
St Louis Children's Hospital	Transplant	St Louis	MO	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$125,000	N/A		N/A	N/A	80% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed $166,500, Payment will be the Transplant Case Rate, Plus 75% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		38.653285	-90.3835452	475.pdf
St Louis Children's Hospital	Transplant	St Louis	MO	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$85,000	N/A		N/A	N/A	80% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed $113,000, Payment will be the Transplant Case Rate, Plus 75% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		38.653285	-90.3835452	475.pdf
St Louis Children's Hospital	Transplant	St Louis	MO	Heart	Heart	Pediatric	Programs of Excellence		$60,000	N/A		N/A	N/A	80% of Billed Charges			Included in Case Rate	80% of Billed Charges	If Billed Charges Exceed $80,000, Payment will be the Transplant Case Rate, Plus 75% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		38.653285	-90.3835452	476.pdf
St Louis Children's Hospital	Transplant	St Louis	MO	Heart/Lung	Heart/Lung	Pediatric	Member's Choice		$180,000	N/A		N/A	N/A	80% of Billed Charges			Included in Case Rate	80% of Billed Charges	If Billed Charges Exceed $232,000, Payment will be the Transplant Case Rate, Plus 75% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		38.653285	-90.3835452	477.pdf
St Louis Children's Hospital	Transplant	St Louis	MO	Kidney	Kidney	Pediatric	Programs of Excellence		$62,000	N/A		N/A	N/A	80% of Billed Charges			Included in Case Rate	80% of Billed Charges	If Billed Charges Exceed $82,000, Payment will be the Transplant Case Rate, Plus 75% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		38.653285	-90.3835452	478.pdf
St Louis Children's Hospital	Transplant	St Louis	MO	Liver	Liver	Pediatric	Programs of Excellence		$120,000	N/A		N/A	N/A	80% of Billed Charges			Included in Case Rate	80% of Billed Charges	If Billed Charges Exceed $160,000, Payment will be the Transplant Case Rate, Plus 75% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		38.653285	-90.3835452	479.pdf
St Louis Children's Hospital	Transplant	St Louis	MO	Lung	Lung	Pediatric	Programs of Excellence		$105,000	N/A		N/A	N/A	80% of Billed Charges			Included in Case Rate	80% of Billed Charges	If Billed Charges Exceed $139,650, Payment will be the Transplant Case Rate, Plus 75% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		38.653285	-90.3835452	480.pdf
Stanford Health Care	Transplant	Palo Alto	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceELITE	$407,000	100	The Inlier Days period Shall begin on the Date of the Ablative Therapy and conclude at the End of the Inlier Days	$20,000	70% of Billed Charges	60% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Inlier Days and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		37.425713	-122.1703694	481.pdf
Stanford Health Care	Transplant	Palo Alto	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceELITE	$522,500	100	The Inlier Days period Shall begin on the Date of the Ablative Therapy and conclude at the End of the Inlier Days	$20,000	70% of Billed Charges	60% of Billed Charges	Reimbursed at Invoice Cost	Reimbursed at Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Inlier Days and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		37.425713	-122.1703694	481.pdf
Stanford Health Care	Transplant	Palo Alto	CA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceELITE	$340,000	60	The Inlier Days period Shall begin on the Date of the Ablative Therapy and conclude at the End of the Inlier Days	$20,000	70% of Billed Charges	60% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Inlier Days and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		37.425713	-122.1703694	481.pdf
Stanford Health Care	Transplant	Palo Alto	CA	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$1,089,000	25		$25,000	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		37.425713	-122.1703694	482.pdf
Stanford Health Care	Transplant	Palo Alto	CA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor: $308,000 \| Living Donor $297,000	10		$25,000	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		37.425713	-122.1703694	483.pdf
Stanford Health Care	Transplant	Palo Alto	CA	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$388,000	20		$25,000	70% of Billed Charges	60% of Billed Charges			First Organ: Included in Case Rate \| Second and any Additional Organs: Shall be Paid at 100% of Invoice Cost	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		37.425713	-122.1703694	484.pdf
Stanford Health Care	Transplant	Palo Alto	CA	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	Cadaveric or Living Donor: $440,000	20		$25,000	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		37.425713	-122.1703694	485.pdf
Stanford Health Care	Transplant	Palo Alto	CA	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	Single or Bilateral: $1,094,500	30		$25,000	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		37.425713	-122.1703694	486.pdf
Stanford Health Care	Transplant	San Francisco	CA	Multi-Organ	Multi-Organ	Adult	Member's Choice		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	Based on Organ with Highest Allowable Days		$25,000	70% of Billed Charges	60% of Billed Charges			First Organ: Included in Case Rate \| Second and any Additional Organs: Shall be Paid at 100% of Invoice Cost	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		37.425713	-122.1703694	487.pdf
Stanford Health Care	Transplant	Palo Alto	CA	Pancreas	Pancreas	Adult	Programs of Excellence		$209,000	20		$25,000	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		37.425713	-122.1703694	488.pdf
Stanford Health Care	Transplant	Palo Alto	CA	Heart/Lung	Heart/Lung	Adult	Member's Choice		$1,650,000	30		$25,000	70% of Billed Charges	60% of Billed Charges			First Organ: Included in Case Rate \| Second and any Additional Organs: Shall be Paid at 100% of Invoice Cost	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		37.425713	-122.1703694	489.pdf
Stanford Health Care	Cellular Immunotherapy	Palo Alto	CA	Cellular Immunotherapy	Cellular Immunotherapy				Charges $0 - $500,000 Pay at 60% \| Charges $500,001 - $1,000,000 Pay at 50% \| Charges $1,000,001 and Above Pay at 40% \| Drug Cost: 110% of Invoice Cost	N/A		N/A	N/A	60% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends 365 Days from Discharge		37.4256448	-122.1704551	490.pdf
Stanford Health Care	Transplant	San Francisco	CA	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates		125% of Region 9, Santa Clara County Locality Fee Schedule	N/A	N/A	N/A	N/A	125% of Region 9, Santa Clara County Locality Fee Schedule	100% of Invoice Cost	N/A			N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 365 Days Later		37.7576948	-122.4727051	491.pdf
Stanford Health Care	Transplant	San Francisco	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates		125% of Region 9, Santa Clara County Locality Fee Schedule	N/A	N/A	N/A	N/A	125% of Region 9, Santa Clara County Locality Fee Schedule	100% of Invoice Cost	100% of Invoice Cost			N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 365 Days Later		37.7576948	-122.4727051	491.pdf
Stanford Health Care	Transplant	San Francisco	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Government Rates		125% of Region 9, Santa Clara County Locality Fee Schedule	N/A	N/A	N/A	N/A	125% of Region 9, Santa Clara County Locality Fee Schedule	100% of Invoice Cost	100% of Invoice Cost			N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 365 Days Later		37.7576948	-122.4727051	491.pdf
Stanford Health Care	Transplant	San Francisco	CA	Heart	Heart	Adult	Government Rates		125% of Region 9, Santa Clara County Locality Fee Schedule	N/A		N/A	N/A	125% of Region 9, Santa Clara County Locality Fee Schedule			100% of Invoice Cost	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 365 Days Later		37.7576948	-122.4727051	492.pdf
Stanford Health Care	Transplant	San Francisco	CA	Heart/Lung	Heart/Lung	Adult	Government Rates		125% of Region 9, Santa Clara County Locality Fee Schedule	N/A		N/A	N/A	125% of Region 9, Santa Clara County Locality Fee Schedule			100% of Invoice Cost	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 365 Days Later		37.7576948	-122.4727051	493.pdf
Stanford Health Care	Transplant	San Francisco	CA	Kidney	Kidney	Adult	Government Rates		125% of Region 9, Santa Clara County Locality Fee Schedule	N/A		N/A	N/A	125% of Region 9, Santa Clara County Locality Fee Schedule			100% of Invoice Cost	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 365 Days Later		37.7576948	-122.4727051	494.pdf
Stanford Health Care	Transplant	San Francisco	CA	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates		125% of Region 9, Santa Clara County Locality Fee Schedule	N/A		N/A	N/A	125% of Region 9, Santa Clara County Locality Fee Schedule			100% of Invoice Cost	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 365 Days Later		37.7576948	-122.4727051	495.pdf
Stanford Health Care	Transplant	San Francisco	CA	Liver	Liver	Adult	Government Rates		125% of Region 9, Santa Clara County Locality Fee Schedule	N/A		N/A	N/A	125% of Region 9, Santa Clara County Locality Fee Schedule			100% of Invoice Cost	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 365 Days Later		37.7576948	-122.4727051	496.pdf
Stanford Health Care	Transplant	San Francisco	CA	Lung	Lung	Adult	Government Rates		125% of Region 9, Santa Clara County Locality Fee Schedule	N/A		N/A	N/A	125% of Region 9, Santa Clara County Locality Fee Schedule			100% of Invoice Cost	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 365 Days Later		37.7576948	-122.4727051	497.pdf
Stanford Health Care	Transplant	San Francisco	CA	Pancreas	Pancreas	Adult	Government Rates		125% of Region 9, Santa Clara County Locality Fee Schedule	N/A		N/A	N/A	125% of Region 9, Santa Clara County Locality Fee Schedule			100% of Invoice Cost	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 365 Days Later		37.7576948	-122.4727051	498.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Heart	Heart	Adult	Member's Choice		$276,500	20		Days 21-40: $6,200 Med/Surg $6,200 ICU/CCU \| Day 41-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost Plus 5%	N/A	Begins at Evaluation	One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	499.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Heart	Heart	Pediatric	Member's Choice		$276,500	20		Days 21-40: $6,200 Med/Surg $6,200 ICU/CCU \| Day 41-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges			Included in Case Rate	105% of Invoice Cost	N/A	Begins at Evaluation	One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	499.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$201,500	20		Days 21-40: $6,200 Med/Surg $6,200 ICU/CCU \| Day 41-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost Plus 5%	N/A	Begins at Evaluation	One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	500.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Kidney/Pancreas	Kidney/Pancreas	Pediatric	Member's Choice		$201,500	20		Days 21-40: $6,200 Med/Surg $6,200 ICU/CCU \| Day 41-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges			Included in Case Rate	105% of Invoice Cost	N/A	Begins at Evaluation	One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	500.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Pancreas	Pancreas	Adult	Programs of Excellence		$144,200	20		Days 21-40: $6,200 Med/Surg $6,200 ICU/CCU \| Day 41-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost Plus 5%	N/A	Begins at Evaluation	One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	501.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Pancreas	Pancreas	Pediatric	Programs of Excellence		$144,200	20		Days 21-40: $6,200 Med/Surg $6,200 ICU/CCU \| Day 41-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges			Included in Case Rate	105% of Invoice Cost	N/A	Begins at Evaluation	One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	501.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$255,600	40		Days 41-60: $6,300 Med/Surg $6,300 ICU/CCU \| Day 61-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	502.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$302,800	40		Days 41-60: $6,300 Med/Surg $6,300 ICU/CCU \| Day 61-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	502.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$179,800	25		Days 41-60: $6,300 Med/Surg $6,300 ICU/CCU \| Day 61-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	502.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$255,600	40		Days 41-60: $6,300 Med/Surg $6,300 ICU/CCU \| Day 61-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	502.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$302,800	40		Days 41-60: $6,300 Med/Surg $6,300 ICU/CCU \| Day 61-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	502.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$179,800	25		Days 41-60: $6,300 Med/Surg $6,300 ICU/CCU \| Day 61-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	502.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceQUALITY	1st Transplant: 100% of Higher Case Rate \| 2nd Transplant: 75% of Second Case Rate	1st Transplant: Global Period for Higher Case Rate \| 2nd Transplant: New Period Begins		Days Associated with Higher Global Days: $6,113 Med/Surg, $6,113 ICU/CCU \| Day Outlier Per Diem Period Ends-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	502.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Adult	Programs of Excellence	PerformanceQUALITY	1st Transplant: 100% of Higher Case Rate \| 2nd Transplant: 75% of Second Case Rate	1st Transplant: Global Period for Higher Case Rate \| 2nd Transplant: New Period Begins		Days Associated with Higher Global Days: $6,113 Med/Surg, $6,113 ICU/CCU \| Day Outlier Per Diem Period Ends-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	502.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Pediatric	Programs of Excellence		1st Transplant: 100% of Higher Case Rate \| 2nd Transplant: 75% of Second Case Rate	1st Transplant: Global Period for Higher Case Rate \| 2nd Transplant: New Period Begins		Days Associated with Higher Global Days: $6,113 Med/Surg, $6,113 ICU/CCU \| Day Outlier Per Diem Period Ends-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	502.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Pediatric	Programs of Excellence		1st Transplant: 100% of Higher Case Rate \| 2nd Transplant: 75% of Second Case Rate	1st Transplant: Global Period for Higher Case Rate \| 2nd Transplant: New Period Begins		Days Associated with Higher Global Days: $6,113 Med/Surg, $6,113 ICU/CCU \| Day Outlier Per Diem Period Ends-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	502.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Kidney	Kidney	Pediatric	Member's Choice		$106,703	15		Days 21-40: $6,200 Med/Surg $6,200 ICU/CCU \| Day 41-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges			Included in Case Rate	105% of Invoice Cost	N/A	Begins at Evaluation	One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	503.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$111,800	15		Days 16-35: $5,914 Med/Surg, $5,914 ICU/CCU \| Day 36-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost Plus 5%	N/A	Begins at Evaluation	One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	503.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Liver	Liver	Pediatric	Member's Choice		Cadaveric Donor: $287,200 \| Living Donor: $299,600	25		Days 21-40: $6,200 Med/Surg $6,200 ICU/CCU \| Day 41-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges			Included in Case Rate	105% of Invoice Cost	N/A	Begins at Evaluation	One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	504.pdf
Strong Memorial Hospital, University of Rochester Medical Center	Transplant	Rochester	NY	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor: $287,200 \| Living Donor: $299,600	25		Days 26-45: $5,914 Med/Surg, $5,914 ICU/CCU \| Day 46-Dishcharge: 60% of Billed Charges	95% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost Plus 5%	N/A	Begins at Evaluation	One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		43.18616	-77.6866099	504.pdf
Swedish Medical Center	Transplant	Seattle	WA	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates		110% of Medicare Allowable	N/A		N/A	80% of Billed Charges	110% of Medicare Allowable			Reimbursed in Accordance with the Medicare Cost Report (Commonly Referred to as the D-4 Report)	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	417.pdf
Swedish Medical Center	Transplant	Seattle	WA	Pancreas	Pancreas	Adult	Government Rates		110% of Medicare Allowable	N/A		N/A	80% of Billed Charges	110% of Medicare Allowable			Reimbursed in Accordance with the Medicare Cost Report (Commonly Referred to as the D-4 Report)	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	417.pdf
Swedish Medical Center	Transplant	Seattle	WA	Kidney	Kidney	Adult	Government Rates		110% of Medicare Allowable	N/A		N/A	80% of Billed Charges	110% of Medicare Allowable			Reimbursed in Accordance with the Medicare Cost Report (Commonly Referred to as the D-4 Report)	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	417.pdf
Swedish Medical Center	Transplant	Seattle	WA	Liver	Liver	Adult	Government Rates		110% of Medicare Allowable	N/A		N/A	80% of Billed Charges	110% of Medicare Allowable			Reimbursed in Accordance with the Medicare Cost Report (Commonly Referred to as the D-4 Report)	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	417.pdf
Swedish Medical Center	Transplant	Seattle	WA	Kidney/Liver	Kidney/Liver	Adult	Government Rates		110% of Medicare Allowable	N/A		N/A	80% of Billed Charges	110% of Medicare Allowable			Reimbursed in Accordance with the Medicare Cost Report (Commonly Referred to as the D-4 Report)	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	417.pdf
Swedish Medical Center	Transplant	Seattle	WA	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		Hospital: $158,000 \| Professional: $16,000	N/A		N/A	80% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	N/A	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	505.pdf
Swedish Medical Center	Transplant	Seattle	WA	Pancreas	Pancreas	Adult	Programs of Excellence		Hospital: $78,332 \| Professional: $8,900	N/A		N/A	80% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	N/A	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	506.pdf
Swedish Medical Center	Transplant	Seattle	WA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor Hospital: $80,000 \| Cadaveric Donor Professional: $10,000 \| Living Donor Hospital: $78,000 \| Living Donor Professional: $10,000	N/A		N/A	80% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	N/A	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	507.pdf
Swedish Medical Center	Transplant	Seattle	WA	Liver	Liver	Adult	Member's Choice		Hospital: $140,000 \| Professional: $16,000	N/A		N/A	80% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	N/A	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	508.pdf
Swedish Medical Center	Transplant	Seattle	WA	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		Hospital: $180,000 \| Professional: $21,000	N/A		N/A	80% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	N/A	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	865.pdf
Tampa General Hospital	Transplant	Tampa	FL	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$98,000	20		$2,200 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	65% of Billed Charges			Reimbursed at Invoice Cost	55% of Billed Charges	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when the Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Date of Transplant		27.9947147	-82.5943645	509.pdf
Tampa General Hospital	Transplant	Tampa	FL	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor: $48,500 \| Living Donor: $42,500	15		$2,200 Med/Surg \| $2,850 ICU/CCU	90% of Billed Charges	65% of Billed Charges			Cadaveric Donor: Reimbursed at Invoice Cost \| Living Donor: Included in Case Rate	55% of Billed Charges	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when the Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Date of Transplant		27.9947147	-82.5943645	510.pdf
Tampa General Hospital	Transplant	Tampa	FL	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	$91,000	18		$2,200 Med/Surg \| $2,850 ICU/CCU	90% of Billed Charges	65% of Billed Charges			Reimbursed at Invoice Cost	55% of Billed Charges	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when the Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Date of Transplant		27.9947147	-82.5943645	511.pdf
Tampa General Hospital	Transplant	Tampa	FL	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	$140,000	20		$2,200 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	65% of Billed Charges			Reimbursed at Invoice Cost	55% of Billed Charges	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when the Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Date of Transplant		27.9947147	-82.5943645	512.pdf
Tampa General Hospital	Transplant	Tampa	FL	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	Single: $120,000 \| Bilateral: $130,000	20		$2,200 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	65% of Billed Charges			Reimbursed at Invoice Cost	55% of Billed Charges	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when the Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Date of Transplant		27.9947147	-82.5943645	513.pdf
Tampa General Hospital	Transplant	Tampa	FL	Pancreas	Pancreas	Adult	Programs of Excellence		$80,000	18		$2,200 Med/Surg \| $2,850 ICU/CCU	90% of Billed Charges	65% of Billed Charges			Reimbursed at Invoice Cost	55% of Billed Charges	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when the Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Date of Transplant		27.9947147	-82.5943645	514.pdf
Texas Children's Hospital	Transplant	Houston	TX	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		Hospital: $85,000 \| Physicians: 70% of Billed Charges	30		$1,800 Med/Surg \| $2,400 ICU/CCU	90% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the First Day of Ablative Therapy and Ends when the Inlier Days have Expired	Ends One (1) Year from Discharge		29.8171037	-95.5417172	515.pdf
Texas Children's Hospital	Transplant	Houston	TX	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		Hospital: $105,000 \| Physicians: 70% of Billed Charges	35		$1,800 Med/Surg \| $2,400 ICU/CCU	90% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the First Day of Ablative Therapy and Ends when the Inlier Days have Expired	Ends One (1) Year from Discharge		29.8171037	-95.5417172	515.pdf
Texas Children's Hospital	Transplant	Houston	TX	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		Hospital: $120,000 \| Physicians: 70% of Billed Charges	40		$1,800 Med/Surg \| $2,400 ICU/CCU	90% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the First Day of Ablative Therapy and Ends when the Inlier Days have Expired	Ends One (1) Year from Discharge		29.8171037	-95.5417172	515.pdf
Texas Children's Hospital	Transplant	Houston	TX	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Pediatric	Programs of Excellence		1st Transplant: Hospital $60,000 Professional 70% \| 2nd Transplant: Hospital $60,000 Professional $19,981	30 for Each Transplant		$1,800 Med/Surg \| $2,400 ICU/CCU	90% of Billed Charges	70% of Billed Charges	Included in Case Rate				60% of Billed Charges	Begins at Evaluation	Begins on the First Day of Ablative Therapy and Ends when the Inlier Days have Expired	Ends One (1) Year from Discharge		29.8171037	-95.5417172	515.pdf
Texas Children's Hospital	Transplant	Houston	TX	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Pediatric	Programs of Excellence		Related: 1st Transplant: Hospital $60,000 Professional 70% \| 2nd Transplant: Hospital $85,000 Professional $19,981 \| Unrelated: 1st Transplant: Hospital $60,000 Professional 70% \| 2nd Transplant: Hospital $95,000 Professional $19,981	Related: 1st Transplant: 30 Days, 2nd Transplant: 35 Days \| Unrelated: 1st Transplant: 30 Days, 2nd Transplant: 40 Days		$1,800 Med/Surg \| $2,400 ICU/CCU	90% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the First Day of Ablative Therapy and Ends when the Inlier Days have Expired	Ends One (1) Year from Discharge		29.8171037	-95.5417172	515.pdf
Texas Children's Hospital	Transplant	Houston	TX	Multi-Organ	Multi-Organ	Pediatric	Member's Choice		70% of Billed Charges	N/A		N/A	N/A	70% of Billed Charges			Reimbursed at Invoice Cost		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when the Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		29.8171037	-95.5417172	516.pdf
Texas Children's Hospital	Transplant	Houston	TX	Heart	Heart	Pediatric	Programs of Excellence		$130,000	30		$1,800 Med/Surg \| $2,400 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends When the Inlier Days Have Expired	Ends One (1) Year from Discharge		29.8171037	-95.5417172	517.pdf
Texas Children's Hospital	Transplant	Houston	TX	Kidney	Kidney	Pediatric	Programs of Excellence		Deceased Donor Hospital: $56,000 \| Deceased Donor Physicians: 70% of Billed Charges \| Living Donor Hospital: $60,000 \| Living Donor Physicians: 70% of Billed Charges	15		$1,800 Med/Surg \| $2,400 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends When the Inlier Days Have Expired	Ends One (1) Year from Discharge		29.8171037	-95.5417172	518.pdf
Texas Children's Hospital	Transplant	Houston	TX	Liver	Liver	Pediatric	Programs of Excellence		Hosptial: $100,000 \| Physicians: 70% of Billed Charges	22		$1,800 Med/Surg \| $2,400 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends When the Inlier Days Have Expired	Ends One (1) Year from Discharge		29.8171037	-95.5417172	519.pdf
Texas Children's Hospital	Transplant	Houston	TX	Lung	Lung	Pediatric	Programs of Excellence		Single Lung Hospital: $110,000 \| Single Lung Physicians: 70% of Billed Charges \| Double Lung Hospital: $150,000 \| Double Lung Physicians: 70% of Billed Charges	30		$1,800 Med/Surg \| $2,400 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost Plus 10%	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends When the Inlier Days Have Expired	Ends One (1) Year from Discharge		29.8171037	-95.5417172	520.pdf
Texas Children's Hospital	Cellular Immunotherapy	Houston	TX	Cellular Immunotherapy	Cellular Immunotherapy				Charges $0 - $500,000 Pay at 65% \| Charges $500,001 - $1,000,000 Pay at 60% \| Charges $1,000,001 and Above Pay at 55% \| Drug Cost: 105% of Wholesale Acquisition Cost (WAC)	N/A		N/A	N/A	70% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends One (1) Year from Discharge		29.8171037	-95.5417172	521.pdf
Texas Children's Hospital	Congenital Heart Defect	Houston	TX	Congenital Heart Defect	Congenital Heart Defect				Surgical Event Hospital: 60% of Billed Charges \| Surgical Event Professional: 70% of Billed Charges \| Inpatient (Med/Surg) Hospital: $1,800 Per Diem \| Inpatient (Med/Surg) Professional: 70% of Billed Charges \| Inpatient (NICU/PICU) Hospital: $2,400 Per Diem \| Inpatient (NICU/PICU) Professional: 70% of Billed Charges \| Inpatient (ECMO) Hospital: $5,000 Per Diem \| Inpatient (ECMO) Professional: 70% of Billed Charges	N/A		N/A	N/A	70% of Billed Charges				105% of Billed Charges	60% of Billed Charges	Begins on the Date of Referral to INTERLINK	Begins Upon Referral to INTERLINK &/Or when Patient is Admitted to Facility	Coverage Remains Active Until Patient No Longer Requires Pediatric Heart Services		29.8171037	-95.5417172	522.pdf
Texas Transplant Institute (Methodist Hospital Specialty and Transplant)	Transplant	San Antonio	TX	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$87,000	12		$2,000 Med/Surg \| $2,000 ICU/CCU	75% of Billed Charges	75% of Billed Charges			Procurement in Local Organ Bank Service Area is Included in Case Rate \| Procurement Outside of Service Area is Invoice Cost	N/A	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 90 Days from Discharge		29.4813568	-98.6548302	523.pdf
Texas Transplant Institute (Methodist Hospital Specialty and Transplant)	Transplant	San Antonio	TX	Pancreas	Pancreas	Adult	Member's Choice		$72,000	12		$2,000 Med/Surg \| $2,000 ICU/CCU	75% of Billed Charges	75% of Billed Charges			Procurement in Local Organ Bank Service Area is Included in Case Rate \| Procurement Outside of Service Area is Invoice Cost	N/A	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 90 Days from Discharge		29.4813568	-98.6548302	524.pdf
Texas Transplant Institute (Methodist Hospital Specialty and Transplant)	Transplant	San Antonio	TX	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$90,000	25		$2,000 Med/Surg \| $2,000 ICU/CCU	75% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			55% of Billed Charges	Begins at Evaluation	Begins on the Day of Mobilization and Ends When the Inlier Days Have Expired	Ends 90 Days from Discharge		29.4813568	-98.6548302	525.pdf
Texas Transplant Institute (Methodist Hospital Specialty and Transplant)	Transplant	San Antonio	TX	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$115,000	40		$2,500 Med/Surg \| $3,000 ICU/CCU	75% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			55% of Billed Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends When the Inlier Days Have Expired	Ends 90 Days from Discharge		29.4813568	-98.6548302	525.pdf
Texas Transplant Institute (Methodist Hospital Specialty and Transplant)	Transplant	San Antonio	TX	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$175,000	40		$2,500 Med/Surg \| $3,000 ICU/CCU	75% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			55% of Billed Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends When the Inlier Days Have Expired	Ends 90 Days from Discharge		29.4813568	-98.6548302	525.pdf
Texas Transplant Institute (Methodist Hospital Specialty and Transplant)	Transplant	San Antonio	TX	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	$85,000	25		$2,000 Med/Surg \| $2,500 ICU/CCU	75% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			55% of Billed Charges	Begins at Evaluation	Begins on the Day of Mobilization and Ends When the Inlier Days Have Expired	Ends 90 Days from Discharge		29.4813568	-98.6548302	525.pdf
Texas Transplant Institute (Methodist Hospital Specialty and Transplant)	Transplant	San Antonio	TX	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	$110,000	40		$2,500 Med/Surg \| $3,000 ICU/CCU	75% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			55% of Billed Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends When the Inlier Days Have Expired	Ends 90 Days from Discharge		29.4813568	-98.6548302	525.pdf
Texas Transplant Institute (Methodist Hospital Specialty and Transplant)	Transplant	San Antonio	TX	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	$170,000	40		$2,500 Med/Surg \| $3,000 ICU/CCU	75% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			55% of Billed Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends When the Inlier Days Have Expired	Ends 90 Days from Discharge		29.4813568	-98.6548302	525.pdf
Texas Transplant Institute (Methodist Hospital Specialty and Transplant)	Transplant	San Antonio	TX	Heart	Heart	Adult	Programs of Excellence	PerformanceELITE	$130,000	15		$1,500 Med/Surg \| $2,500 ICU/CCU	75% of Billed Charges	75% of Billed Charges			Procurement in Local Organ Bank Service Area is Included in Case Rate \| Procurement Outside of Service Area is Invoice Cost	Reimbursed at Invoice Cost	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 90 Days from Discharge		29.4813568	-98.6548302	526.pdf
Texas Transplant Institute (Methodist Hospital Specialty and Transplant)	Transplant	San Antonio	TX	Kidney	Kidney	Adult	Member's Choice		Cadaveric Donor: $62,000 \| Living Donor: $52,000	12		$2,000 Med/Surg \| $2,000 ICU/CCU	75% of Billed Charges	75% of Billed Charges			Procurement in Local Organ Bank Service Area is Included in Case Rate \| Procurement Outside of Service Area is Invoice Cost	N/A	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 90 Days from Discharge		29.4813568	-98.6548302	527.pdf
Texas Transplant Institute (Methodist Hospital Specialty and Transplant)	Transplant	San Antonio	TX	Liver	Liver	Adult	Member's Choice		$120,000	15		$1,500 Med/Surg \| $2,500 ICU/CCU	75% of Billed Charges	75% of Billed Charges			Procurement in Local Organ Bank Service Area is Included in Case Rate \| Procurement Outside of Service Area is Invoice Cost	N/A	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 90 Days from Discharge		29.4813568	-98.6548302	528.pdf
The Jewish Hospital	Transplant	Cincinnati	OH	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$145,923	25		$3,546 Med/Surg \| $4,223 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	N/A			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.136319	-84.6106124	529.pdf
The Jewish Hospital	Transplant	Cincinnati	OH	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$247,912	30		$3,546 Med/Surg \| $4,223 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.136319	-84.6106124	529.pdf
The Jewish Hospital	Transplant	Cincinnati	OH	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$310,673	40		$3,546 Med/Surg \| $4,223 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.136319	-84.6106124	529.pdf
The Jewish Hospital	Transplant	Cincinnati	OH	Tandem (Auto-to-Auto)	Tandem Auto to Auto	Adult	Member's Choice		$262,661	1st: 25 \| 2nd: 25		$3,546 Med/Surg \| $4,223 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	N/A			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.136319	-84.6106124	529.pdf
The Jewish Hospital	Transplant	Cincinnati	OH	Tandem (Auto-to-Allo, Related)	Tandem Auto to Allo	Adult	Member's Choice		$331,013	1st: 25 \| 2nd: 30		$3,546 Med/Surg \| $4,223 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.136319	-84.6106124	529.pdf
The Jewish Hospital	Transplant	Cincinnati	OH	Tandem (Auto-to-Allo, Unrelated)	Tandem Auto to Allo	Adult	Member's Choice		$392,266	1st: 25 \| 2nd: 30		$3,546 Med/Surg \| $4,223 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.136319	-84.6106124	529.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$165,000	30		$2,000 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate	Included in Case Rate			61% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Day 101 Post Discharge		41.2918376	-96.1514595	530.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$165,000	30		$2,000 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate	Included in Case Rate			61% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Day 101 Post Inlier Days Period		41.2918376	-96.1514595	530.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$190,000	32		$2,000 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate	Included in Case Rate			61% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Day 101 Post Discharge		41.2918376	-96.1514595	530.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$190,000	32		$2,000 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate	Included in Case Rate			61% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	One (1) Year from Day 31 Post Inlier Days Period		41.2918376	-96.1514595	530.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$110,000	20		$2,000 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate	N/A			61% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Day 31 Post Discharge		41.2918376	-96.1514595	530.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$110,000	20		$2,000 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate	Included in Case Rate			61% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	One (1) Year from Day 31 Post Inlier Days Period		41.2918376	-96.1514595	530.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Member's Choice		75% of Billed Charges	N/A		N/A	N/A	75% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Day 101 Post Inlier Days Period		41.2918376	-96.1514595	530.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Blood/Marrow (Cord Blood)	Cord Blood	Pediatric	Programs of Excellence		75% of Billed Charges	N/A		N/A	N/A	75% of Billed Charges	75% of Billed Charges	75% of Billed Charges			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Day 31 Post Discharge		41.2918376	-96.1514595	530.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Blood/Marrow (Tandem Auto-to-Allo)	Tandem Auto to Allo	Adult	Member's Choice		1st: $110,000; 2nd (Related): $132,000 \| 1st: $110,000; 2nd (Unrelated): $152,000	20, 30 \| 20, 32		$2,000 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate	Included in Case Rate			61% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Day 101 Post Inlier Days Period		41.2918376	-96.1514595	530.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Tandem (Auto-to-Allo)	Tandem Auto to Allo	Pediatric	Programs of Excellence		1st: $110,000; 2nd (Related): $132,000 \| 1st: $110,000; 2nd (Unrelated): $152,000	20, 30 \| 20, 32		$2,000 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate	Included in Case Rate			61% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Day 101 Post Inlier Days Period		41.2918376	-96.1514595	530.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Blood/Marrow (Tandem Auto-to-Auto)	Tandem Auto to Auto	Adult	Member's Choice		1st: $110,000 \| 2nd: $88,000	20 \| 20		$2,000 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate	Included in Case Rate			61% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Day 101 Post Inlier Days Period		41.2918376	-96.1514595	530.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Tandem (Auto-to-Auto)	Tandem Auto to Auto	Pediatric	Programs of Excellence		1st: $110,000 \| 2nd: $88,000	20 \| 20		$2,000 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate	Included in Case Rate			61% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Day 101 Post Inlier Days Period		41.2918376	-96.1514595	530.pdf
The Nebraska Medical Center	Cancer	Omaha	NE	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															41.2918376	-96.1514595	531.pdf
The Nebraska Medical Center	Destination VAD	Omaha	NE	Destination VAD	Destination VAD				$285,000	N/A		Inpatient Per Diem: $2,900 Med/Surg \| $3,600 ICU/CCU	Inpatient: 90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges				100% of Invoice Cost	Inpatient Stay: 62% of Billed Charges	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		41.2918376	-96.1514595	532.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$225,000	18		$2,500 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost plus 5%	61% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Day 91 Post Discharge		41.2918376	-96.1514595	532.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Pancreas	Pancreas	Adult	Programs of Excellence		$130,000	18		$2,500 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost plus 5%	61% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Day 91 Post Discharge		41.2918376	-96.1514595	534.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Intestine	Intestine	Pediatric	Programs of Excellence		75% of Billed Charges	N/A		N/A	N/A	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost plus 5%	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Day 91 Post Discharge		41.2918376	-96.1514595	535.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Intestine	Intestine	Adult	Member's Choice		75% of Billed Charges	N/A		N/A	N/A	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost plus 5%	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Day 91 Post Discharge		41.2918376	-96.1514595	535.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Kidney	Kidney	Pediatric	Programs of Excellence		$115,000	12 Patient \| 7 Donor		$2,500 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost plus 5%	61% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Day 91 Post Discharge		41.2918376	-96.1514595	537.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$110,000	12 Patient \| 7 Donor		$2,500 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost plus 5%	61% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Day 91 Post Discharge		41.2918376	-96.1514595	538.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$145,000	19		$2,500 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost plus 5%	61% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Day 91 Post Discharge		41.2918376	-96.1514595	539.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Liver	Liver	Pediatric	Programs of Excellence		$195,000	25 Patient \| 7 Donor		$2,500 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost plus 5%	61% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Day 91 Post Discharge		41.2918376	-96.1514595	540.pdf
The Nebraska Medical Center	Transplant	Omaha	NE	Liver	Liver	Adult	Member's Choice		$190,000	20 Patient \| 7 Donor		$2,500 Med/Surg \| $3,100 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost plus 5%	61% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Day 91 Post Discharge		41.2918376	-96.1514595	541.pdf
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Blood/Marrow (Tandem Autologous-to-Autologous)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceSELECT	1st Auto: $131,923 \| 2nd Auto: $65,961	28 \| 28		65% of Billed Charges	80% of Billed Charges	70% of Billed Charges	Reimbursed at Invoice Cost	Reimbursed at Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.0024768	-75.1882393	533.pdf
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $185,826 \| Professional: $15,604	28		65% of Billed Charges	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.0024768	-75.1882393	533.pdf
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $249,037 \| Professional: $33,959	35		65% of Billed Charges	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.0024768	-75.1882393	533.pdf
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $284,059 \| Professional: $35,109	30		65% of Billed Charges	80% of Billed Charges	70% of Billed Charges	Reimbursed at Invoice Cost	Reimbursed at Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.0024768	-75.1882393	533.pdf
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Heart	Heart	Adult	Member's Choice		Hospital: $286,540 \| Professional: $48,229	30		65% of Billed Charges	80% of Billed Charges	70% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.0024768	-75.1882393	536.pdf
Thomas Jefferson University Hospital	Destination VAD	Philadelphia	PA	Destination VAD	Destination VAD				Surgical Event: 70% of Billed Charges	N/A		Inpatient Per Diem: $4,468	Inpatient Services: Lesser of 90% of Billed Charges or $3,976	70% of Billed Charges \| VAD Maintenance & Supplies: 115% of Invoice Cost				100% of Invoice Cost	Inpatient Services: Lesser of 90% of Billed Charges or $3,976, but never less than 50% of Billed Charges	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		40.0024768	-75.1882393	536.pdf
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Pancreas	Pancreas	Adult	Programs of Excellence		Hospital: $129,086 \| Professional: $27,662	18		65% of Billed Charges	80% of Billed Charges	70% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends One (1) Year from Discharge		40.0024768	-75.1882393	542.pdf
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor Hospital: $129,086; Cadaveric Donor Professional: $16,172 \| Living Donor Hospital: $156,037; Living Donor Professional: $20,284	8		65% of Billed Charges	80% of Billed Charges	70% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.0024768	-75.1882393	543.pdf
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		Hospital: $180,861 \| Professional: $31,917	12		65% of Billed Charges	80% of Billed Charges	70% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.0024768	-75.1882393	544.pdf
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor Hospital: $275,192; Cadaveric Donor Professional: $52,769 \| Living Donor Hospital: $296,469; Living Donor Professional: $61,280	Cadaveric Donor: 20 \| Living Donor: 30		65% of Billed Charges	80% of Billed Charges	70% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.0024768	-75.1882393	545.pdf
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Multi-Organ	Multi-Organ	Adult	Member's Choice		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	Equal to Organ with Longest Duration		65% of Billed Charges	80% of Billed Charges	70% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.0024768	-75.1882393	546.pdf
Thomas Jefferson University Hospital	Bariatric	Philadelphia	PA	Bariatric	Bariatric				Duodenal Switch: $22,697 \| Gastric Banding: $21,277 \| Gastric Bypass: Hospital: $24,115; Professional: $6,667 \| Gastric Sleeve: Hospital: $35,463; Professional $5,816	Duodenal Switch: 3 \| Gastric Banding: 2 \| Gastric Bypass: 3 \| Gastric Sleeve: 2		$3,547	80% of Billed Charges	70% of Billed Charges					N/A	Begins at Evaluation and Ends on the Day of Surgery	Begins on the Day of Surgery and Ends when the Number of Inlier Days and Applicable Outlier Days have Expired	Begins at Discharge and Ends One (1) Year Later		40.0024768	-75.1882393	547.pdf
Tufts Medical Center	Transplant	Boston	MA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$135,000	N/A		N/A	100% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed $236,250, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		42.3144556	-71.0403236	548.pdf
Tufts Medical Center	Transplant	Boston	MA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$165,000	N/A		N/A	100% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed $288,750, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		42.3144556	-71.0403236	548.pdf
Tufts Medical Center	Transplant	Boston	MA	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$95,000	N/A		N/A	100% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed $166,250, Payment will be the Transplant Case Rate, Plus 50% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		42.3144556	-71.0403236	548.pdf
Tufts Medical Center	Transplant	Boston	MA	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Member's Choice		1st Transplant: $95,000 \| 2nd Transplant: $124,688	N/A		N/A	100% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed $166,250 for the First Transplant or $124,688 for the second Transplant, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		42.3144556	-71.0403236	548.pdf
Tufts Medical Center	Transplant	Boston	MA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$90,000	N/A		N/A	100% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost	If Billed Charges Exceed $157,500, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		42.3144556	-71.0403236	549.pdf
Tufts Medical Center	Transplant	Boston	MA	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$210,000	N/A		N/A	100% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost	If Billed Charges Exceed $367,000, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		42.3144556	-71.0403236	550.pdf
Tufts Medical Center	Destination VAD	Boston	MA	Destination VAD	Destination VAD				Surgical Event: 60% of Billed Charges	N/A		Hospital: $3,500 \| Professional: $500	100% of Billed Charges	70% of Billed Charges \| VAD Maintenance & Supplies: 105% of Invoice Cost				100% of Invoice Cost	N/A	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		42.3143285	-71.0404949	550.pdf
Tufts Medical Center	Transplant	Boston	MA	Multi-Organ	Multi-Organ	Adult	Member's Choice		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	N/A		N/A	100% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost	If Billed Charges Exceed 1.75 Times the Case Rate, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		42.3143285	-71.0404949	551.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$271,973	N/A		N/A	90% of Billed Charges	80% of Billed Charges	75% of Billed Charges	100% of Billed Charges			Charges in Excess of $433,538 Shall be Reimbursed at 68% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	552.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$312,361	N/A		N/A	90% of Billed Charges	80% of Billed Charges	75% of Billed Charges	100% of Billed Charges			Charges in Excess of $527,786 Shall be Reimbursed at 68% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	552.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	Breast Cancer: $188,495 \| Non-Breast Cancer: $228,884	N/A		N/A	90% of Billed Charges	80% of Billed Charges	75% of Billed Charges	100% of Billed Charges			Charges in Excess of $347,366 (Breast Cancer) or $409,302 (Non-Breast Cancer), Shall be Reimbursed at 68% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	552.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$271,973	N/A		N/A	90% of Billed Charges	80% of Billed Charges	75% of Billed Charges	100% of Billed Charges			Charges in Excess of $433,538 Shall be Reimbursed at 68% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	552.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$312,361	N/A		N/A	90% of Billed Charges	80% of Billed Charges	75% of Billed Charges	100% of Billed Charges			Charges in Excess of $527,786 Shall be Reimbursed at 68% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	552.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		Breast Cancer: $188,495 \| Non-Breast Cancer: $228,884	N/A		N/A	90% of Billed Charges	80% of Billed Charges	75% of Billed Charges	100% of Billed Charges			Charges in Excess of $347,366 (Breast Cancer) or $409,302 (Non-Breast Cancer), Shall be Reimbursed at 68% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	552.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Heart	Heart	Adult	Member's Choice		$352,755	N/A		N/A	90% of Billed Charges	80% of Billed Charges			Cadaveric Donor: 100% of Billed Charges \| Living Donor: 75% of Billed Charge	80% of Billed Charges	Charges in Excess of $554,713 Shall be Reimbursed at 68% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	553.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Heart	Heart	Pediatric	Programs of Excellence		$352,755	N/A		N/A	90% of Billed Charges	80% of Billed Charges			Cadaveric Donor: 100% of Billed Charges \| Living Donor: 75% of Billed Charge	80% of Billed Charges	Charges in Excess of $554,713 Shall be Reimbursed at 68% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	553.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor: $113,094 \| Living Donor: $102,326	N/A		N/A	90% of Billed Charges	80% of Billed Charges			Cadaveric Donor: 100% of Billed Charges \| Living Donor: 75% of Billed Charge	80% of Billed Charges	Charges in Excess of $199,263 (Cadaveric) or $185,803 (Living Donor) Shall be Reimbursed at 68% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	554.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Kidney	Kidney	Pediatric	Member's Choice		Cadaveric Donor: $113,094 \| Living Donor: $102,326	N/A		N/A	90% of Billed Charges	80% of Billed Charges			Cadaveric Donor: 100% of Billed Charges \| Living Donor: 75% of Billed Charge	80% of Billed Charges	Charges in Excess of $199,263 (Cadaveric) or $185,803 (Living Donor) Shall be Reimbursed at 68% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	554.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceELITE	$196,573	N/A		N/A	90% of Billed Charges	80% of Billed Charges			Cadaveric Donor: 100% of Billed Charges \| Living Donor: 75% of Billed Charge	80% of Billed Charges	Charges in Excess of $339,287, Shall be Reimbursed at 68% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	555.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Kidney/Pancreas	Kidney/Pancreas	Pediatric	Member's Choice		$196,573	N/A		N/A	90% of Billed Charges	80% of Billed Charges			Cadaveric Donor: 100% of Billed Charges \| Living Donor: 75% of Billed Charge	80% of Billed Charges	Charges in Excess of $339,287, Shall be Reimbursed at 68% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	555.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor: $290,822 \| Living Donor: $266,585	N/A		N/A	90% of Billed Charges	80% of Billed Charges			Cadaveric Donor: 100% of Billed Charges \| Living Donor: 75% of Billed Charge	80% of Billed Charges	Charges in Excess of $476,625 (Cadaveric) or $452,387 (Living Donor), Shall be Reimbursed at 68% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	556.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Lung	Lung	Adult	Programs of Excellence	PerformanceELITE	Single: $228,884 \| Bilateral: $263,892	N/A		N/A	90% of Billed Charges	80% of Billed Charges			Cadaveric Donor 100% of Billed Charges	80% of Billed Charges	Charges in Excess of $403,916 (Single Lung) or $468,540 (Bilateral Lung), Shall be Reimbursed at 68% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	557.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Lung	Lung	Pediatric	Programs of Excellence		Cadaveric Donor: $290,822 \| Living Donor: $266,585	N/A		N/A	90% of Billed Charges	80% of Billed Charges			Cadaveric Donor 100% of Billed Charges	80% of Billed Charges	Charges in Excess of $476,625 (Cadaveric) or $452,387 (Living Donor), Shall be Reimbursed at 68% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	557.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Multi-Organ	Multi-Organ	Adult	Member's Choice		75% of Billed Charges	N/A		N/A	N/A	80% of Billed Charges			Cadaveric Donor: 100% of Billed Charges \| Living Donor: 75% of Billed Charge	80% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	558.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Multi-Organ	Multi-Organ	Pediatric	Member's Choice		75% of Billed Charges	N/A		N/A	N/A	80% of Billed Charges			Cadaveric Donor: 100% of Billed Charges \| Living Donor: 75% of Billed Charge	80% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	558.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Heart/Lung	Heart/Lung	Adult	Member's Choice		75% of Billed Charges	N/A		N/A	N/A	80% of Billed Charges			Cadaveric Donor: 100% of Billed Charges \| Living Donor: 75% of Billed Charge	80% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	559.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Heart/Lung	Heart/Lung	Pediatric	Member's Choice		75% of Billed Charges	N/A		N/A	N/A	80% of Billed Charges			Cadaveric Donor: 100% of Billed Charges \| Living Donor: 75% of Billed Charge	80% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	559.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Pancreas	Pancreas	Adult	Programs of Excellence		$153,488	N/A		N/A	90% of Billed Charges	80% of Billed Charges			Cadaveric Donor: 100% of Billed Charges \| Living Donor: 75% of Billed Charge	80% of Billed Charges	Charges in Excess of $271,973 Shall be Reimbursed at 68% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	560.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Pancreas	Pancreas	Pediatric	Programs of Excellence		$153,488	N/A		N/A	90% of Billed Charges	80% of Billed Charges			Cadaveric Donor: 100% of Billed Charges \| Living Donor: 75% of Billed Charge	80% of Billed Charges	Charges in Excess of $271,973 Shall be Reimbursed at 68% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	560.pdf
UF Health Shands Hospital	Transplant	Gainesville	FL	Liver	Liver	Pediatric	Member's Choice		Single: $228,884 \| Bilateral: $263,892	N/A		N/A	90% of Billed Charges	80% of Billed Charges			Cadaveric Donor: 100% of Billed Charges \| Living Donor: 75% of Billed Charge	80% of Billed Charges	Charges in Excess of $403,916 (Single Lung) or $468,540 (Bilateral Lung), Shall be Reimbursed at 68% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.6864012	-82.3897859	561.pdf
University Hospital, University of Texas Health Science Center	Transplant	San Antonio	TX	Kidney	Kidney	Pediatric	Member's Choice		Cadaveric Donor \| Hospital: $96,579 \| Physician: $22,716 \| Living Donor \| Hospital: $85,848 \| Physician: $28,694	N/A		N/A	90% of Billed Charges	75% of Billed Charges			Reimbursed at Invoice Cost	N/A	If Billed Charges Exceed $241,449 (Cadaveric Hospital) or $214,621 (Living Hospital), and $56,790 (Cadaveric Physician) or $71,735 (Living Physician), Payment will be the Transplant Case Rate Plus 70% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.4813568	-98.6548302	562.pdf
University Hospital, University of Texas Health Science Center	Transplant	San Antonio	TX	Liver	Liver	Pediatric	Member's Choice		Cadaveric Donor \| Hospital: $193,790 \| Physician: $60,973 \| Living Donor \| Hospital: $181,797 \| Physician: $65,158	N/A		N/A	90% of Billed Charges	75% of Billed Charges			Reimbursed at Invoice Cost	N/A	If Billed Charges Exceed $484,476 (Cadaveric Hospital), $454,492 (Living Hospital) or $152,433 (Cadaveric Physician), $162,895 (Living Physician), Payment will be the Transplant Case Rate Plus 70% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.4813568	-98.6548302	563.pdf
University Hospital, University of Texas Health Science Center	Transplant	San Antonio	TX	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor \| Hospital: $193,790 \| Physician: $60,973 \| Living Donor \| Hospital: $181,797 \| Physician: $65,158	N/A		N/A	90% of Billed Charges	75% of Billed Charges			Reimbursed at Invoice Cost	N/A	If Billed Charges Exceed $484,476 (Cadaveric Hospital), $454,492 (Living Hospital) or $152,433 (Cadaveric Physician), $162,895 (Living Physician), Payment will be the Transplant Case Rate Plus 70% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.4813568	-98.6548302	563.pdf
University Hospital, University of Texas Health Science Center	Transplant	San Antonio	TX	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor \| Hospital: $100,367 \| Physician: $21,520 \| Living Donor \| Hospital: $89,005 \| Physician: $26,303	N/A		N/A	90% of Billed Charges	75% of Billed Charges			Reimbursed at Invoice Cost	N/A	If Billed Charges Exceed $250,917 (Cadaveric Hospital), $222,512 (Living Hospital) or $53,800 (Cadaveric Physician), $65,758 (Living Physician), Payment will be the Transplant Case Rate Plus 70% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.4813568	-98.6548302	564.pdf
University Hospital, University of Texas Health Science Center	Transplant	San Antonio	TX	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	Single Lung \|Hospital: $229,455 \| Physician: $45,431 \| Bilateral Lung \| Hospital: $286,582 \| Physician: $50,214	N/A		N/A	90% of Billed Charges	75% of Billed Charges			Reimbursed at Invoice Cost	N/A	If Billed Charges Exceed $573,638 (Single Hospital), $716,456 (Double Hospital) or $113,578 (Single Physician), $125,535 (Double Physician), Payment will be the Transplant Case Rate Plus 70% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		29.4813568	-98.6548302	565.pdf
University Hospital, University of Texas Health Science Center	Transplant	San Antonio	TX	Kidney	Kidney	Adult	Government Rates		Hospital: 120% of CMS Medicare Rate \| Professional: 160% of CMS Medicare Rate	N/A		N/A	N/A	Hospital: 120% of CMS Medicare Rate \| Professional: 160% of CMS Medicare Rate			100% of Invoice Cost	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		29.4813568	-98.6548302	567.pdf
University Hospital, University of Texas Health Science Center	Transplant	San Antonio	TX	Kidney/Liver	Kidney/Liver	Adult	Government Rates		Hospital: 120% of CMS Medicare Rate \| Professional: 160% of CMS Medicare Rate	N/A		N/A	N/A	Hospital: 120% of CMS Medicare Rate \| Professional: 160% of CMS Medicare Rate			100% of Invoice Cost	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		29.4813568	-98.6548302	568.pdf
University Hospital, University of Texas Health Science Center	Transplant	San Antonio	TX	Liver	Liver	Adult	Government Rates		Hospital: 120% of CMS Medicare Rate \| Professional: 160% of CMS Medicare Rate	N/A		N/A	N/A	Hospital: 120% of CMS Medicare Rate \| Professional: 160% of CMS Medicare Rate			100% of Invoice Cost	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		29.4813568	-98.6548302	569.pdf
University Hospital, University of Texas Health Science Center	Transplant	San Antonio	TX	Liver	Liver	Pediatric	Government Rates		Hospital: 120% of CMS Medicare Rate \| Professional: 160% of CMS Medicare Rate	N/A		N/A	N/A	Hospital: 120% of CMS Medicare Rate \| Professional: 160% of CMS Medicare Rate			100% of Invoice Cost	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		29.4813568	-98.6548302	569.pdf
University Hospital, University of Texas Health Science Center	Transplant	San Antonio	TX	Lung	Lung	Adult	Government Rates		Hospital: 120% of CMS Medicare Rate \| Professional: 160% of CMS Medicare Rate	N/A		N/A	N/A	Hospital: 120% of CMS Medicare Rate \| Professional: 160% of CMS Medicare Rate			100% of Invoice Cost	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		29.4813568	-98.6548302	570.pdf
University Hospital, University of Texas Health Science Center	Transplant	San Antonio	TX	Multi-Organ	Multi-Organ	Pediatric	Government Rates		Hospital: 120% of CMS Medicare Rate \| Professional: 160% of CMS Medicare Rate	N/A		N/A	N/A	Hospital: 120% of CMS Medicare Rate \| Professional: 160% of CMS Medicare Rate			100% of Invoice Cost	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		29.4813568	-98.6548302	572.pdf
University Hospital, University of Texas Health Science Center	Transplant	San Antonio	TX	Multi-Organ	Multi-Organ	Adult	Government Rates		Hospital: 120% of CMS Medicare Rate \| Professional: 160% of CMS Medicare Rate	N/A		N/A	N/A	Hospital: 120% of CMS Medicare Rate \| Professional: 160% of CMS Medicare Rate			100% of Invoice Cost	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		29.4813568	-98.6548302	572.pdf
University Hospitals of Cleveland	Transplant	Cleveland	OH	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$171,600	30		Hospital: $6,760 \| Professional: 75% of Billed Charges	85% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			58% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.4975107	-81.7760709	573.pdf
University Hospitals of Cleveland	Transplant	Cleveland	OH	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$286,000	40		Hospital: $6,760 \| Professional: 75% of Billed Charges	85% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			58% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.4975107	-81.7760709	573.pdf
University Hospitals of Cleveland	Transplant	Cleveland	OH	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$348,400	40		Hospital: $6,760 \| Professional: 75% of Billed Charges	85% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			58% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.4975107	-81.7760709	573.pdf
University Hospitals of Cleveland	Transplant	Cleveland	OH	Tandem (Auto-to-Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceQUALITY	1st: $171,600 \| 2nd: $121,550	30		Hospital: $6,760 \| Professional: 75% of Billed Charges	85% of Billed Charges		Included in Case Rate	Included in Case Rate			58% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year from Discharge		41.4975107	-81.7760709	573.pdf
University Hospitals of Cleveland	Transplant	Cleveland	OH	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Programs of Excellence	PerformanceQUALITY	$436,800	30		Hospital: $6,760 \| Professional: 75% of Billed Charges	85% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			58% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year from Discharge		41.4975107	-81.7760709	573.pdf
University Hospitals of Cleveland	Transplant	Cleveland	OH	Heart	Heart	Adult	Member's Choice		$312,000	27		Hospital: $6,760 \| Professional: 75% of Billed Charges	85% of Billed Charges	75% of Billed Charges			Included in Case Rate	Included in Case Rate	58% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.4975107	-81.7760709	574.pdf
University Hospitals of Cleveland	Transplant	Cleveland	OH	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$142,480	12		Hospital: $6,760 \| Professional: 75% of Billed Charges	85% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	58% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.4975107	-81.7760709	575.pdf
University Hospitals of Cleveland	Transplant	Cleveland	OH	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$239,200	18		Hospital: $6,760 \| Professional: 75% of Billed Charges	85% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	58% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.4975107	-81.7760709	576.pdf
University Hospitals of Cleveland	Transplant	Cleveland	OH	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	$286,000	20		Hospital: $6,760 \| Professional: 75% of Billed Charges	85% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	58% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.4975107	-81.7760709	577.pdf
University Hospitals of Cleveland	Transplant	Cleveland	OH	Lung	Lung	Adult	Member's Choice		$291,200	25		Hospital: $6,760 \| Professional: 75% of Billed Charges	85% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	58% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.4975107	-81.7760709	578.pdf
University Hospitals of Cleveland	Transplant	Cleveland	OH	Pancreas	Pancreas	Adult	Programs of Excellence		$171,600	16		Hospital: $6,760 \| Professional: 75% of Billed Charges	85% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	58% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.4975107	-81.7760709	579.pdf
University Hospitals of Cleveland	Transplant	Cleveland	OH	Blood/Marrow (Autologous)	Autologous	Pediatric	Member's Choice		75% of Billed Charges	30		N/A	N/A	75% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year from Discharge		41.4975107	-81.7760709	580.pdf
University Hospitals of Cleveland	Transplant	Cleveland	OH	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Member's Choice		75% of Billed Charges	35		N/A	N/A	75% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year from Discharge		41.4975107	-81.7760709	580.pdf
University Hospitals of Cleveland	Transplant	Cleveland	OH	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Member's Choice		75% of Billed Charges	40		N/A	N/A	75% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year from Discharge		41.4975107	-81.7760709	580.pdf
University Hospitals of Cleveland	Transplant	Cleveland	OH	Tandem (Auto-to-Auto)	Tandem Auto to Auto	Pediatric	Member's Choice		75% of Billed Charges	1st: 30 \| 2nd: 30		N/A			Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year from Discharge		41.4975107	-81.7760709	580.pdf
University Hospitals of Cleveland	Transplant	Cleveland	OH	Blood/Marrow (Cord Blood)	Cord Blood	Pediatric	Member's Choice		75% of Billed Charges	40		N/A	N/A	75% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier Days have Expired	Ends One (1) Year from Discharge		41.4975107	-81.7760709	580.pdf
University Hospitals of Cleveland	Transplant	Cleveland	OH	Kidney	Kidney	Pediatric	Member's Choice		75% of Billed Charges	35		N/A	N/A	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.4975107	-81.7760709	581.pdf
University Hospitals of Cleveland	Cancer	Cleveland	OH	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															41.4975107	-81.7760709	582.pdf
University of Alabama Hospital	Transplant	Birmingham	AL	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$124,355	N/A	N/A	N/A	90% of Billed Charges	90% of Billed Charges	Included in Case Rate	N/A			If Billed Charges Exceed $165,750, Payment Shall be the Case Rate Plus 85% of the Excess Charges	Begins at Evaluation	Begins on the Day of Transplant Admission and Ends at Discharge	Ends 365 Days from Discharge		33.5314448	-86.9902206	583.pdf
University of Alabama Hospital	Transplant	Birmingham	AL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	Sibling: $150,195 \| Family: $176,673	N/A	N/A	N/A	90% of Billed Charges	90% of Billed Charges	Included in Case Rate	N/A			If Billed Charges Exceed $200,260 (Sibling) or $235,578 (Other Family), Then Payment Shall be the Case Rate Plus 85% of the Excess Charges	Begins at Evaluation	Begins on the Day of Transplant Admission and Ends at Discharge	Ends 365 Days from Discharge		33.5314448	-86.9902206	583.pdf
University of Alabama Hospital	Transplant	Birmingham	AL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$208,675	N/A	N/A	N/A	90% of Billed Charges	90% of Billed Charges	NMDP and HLA Typing Charges Shall be Reimbursed at 90% of Billed Charges	NMDP and HLA Typing Charges Shall be Reimbursed at 90% of Billed Charges			If Billed Charges Exceed $278,248, Payment Shall be the Case Rate Plus 85% of the Excess Charges	Begins at Evaluation	Begins on the Day of Transplant Admission and Ends at Discharge	Ends 365 Days from Discharge		33.5314448	-86.9902206	583.pdf
University of Alabama Hospital	Transplant	Birmingham	AL	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$130,237	18		85% of Billed Charges	85% of Billed Charges	90% of Billed Charges			Included in Case Rate	N/A	In no Event will less than 75% of Billed Charges be Paid	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		33.5314448	-86.9902206	584.pdf
University of Alabama Hospital	Transplant	Birmingham	AL	Heart	Heart	Pediatric	Programs of Excellence		N/A	N/A		N/A	N/A	N/A			N/A	N/A	N/A	N/A	N/A	N/A		33.5314448	-86.9902206	584.pdf
University of Alabama Hospital	Destination VAD	Birmingham	AL	Destination VAD	Destination VAD				Lesser of 85% of Billed Charges or $141,799 \| If Charges Exceed $212,500, 85% of Billed Charges Thereafter	4		N/A	85% of Billed Charges	90% of Billed Charges				Included in the Case Rate	$212,500 & 85% of Billed Charges Thereafter	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		33.5312176	-86.9203481	584.pdf
University of Alabama Hospital	Transplant	Birmingham	AL	Heart/Lung	Heart/Lung	Adult	Member's Choice		85% of Billed Charges	N/A		85% of Billed Charges	N/A	90% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		33.5314448	-86.9902206	585.pdf
University of Alabama Hospital	Transplant	Birmingham	AL	Heart/Lung	Heart/Lung	Pediatric	Member's Choice		N/A	N/A		N/A	N/A	N/A			N/A	N/A	N/A	N/A	N/A	N/A		33.5314448	-86.9902206	585.pdf
University of Alabama Hospital	Transplant	Birmingham	AL	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$57,401	12		85% of Billed Charges	85% of Billed Charges	90% of Billed Charges			Included in Case Rate	N/A	In no Event will less than 75% of Billed Charges be Paid	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		33.5314448	-86.9902206	586.pdf
University of Alabama Hospital	Transplant	Birmingham	AL	Kidney	Kidney	Pediatric	Member's Choice		$57,401	12		85% of Billed Charges	85% of Billed Charges	90% of Billed Charges			Included in Case Rate	N/A	N/A	N/A	N/A	N/A		33.5314448	-86.9902206	586.pdf
University of Alabama Hospital	Transplant	Birmingham	AL	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	$83,619	16		85% of Billed Charges	85% of Billed Charges	90% of Billed Charges			Included in Case Rate	N/A	In no Event will less than 75% of Billed Charges be Paid	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		33.5314448	-86.9902206	587.pdf
University of Alabama Hospital	Transplant	Birmingham	AL	Kidney/Pancreas	Kidney/Pancreas	Pediatric	Member's Choice		$83,619	16		85% of Billed Charges	85% of Billed Charges	90% of Billed Charges			Included in Case Rate	N/A	In no Event will less than 75% of Billed Charges be Paid	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		33.5314448	-86.9902206	587.pdf
University of Alabama Hospital	Transplant	Birmingham	AL	Liver	Liver	Adult	Member's Choice		$160,208	23		85% of Billed Charges	85% of Billed Charges	90% of Billed Charges			Included in Case Rate	N/A	In no Event will less than 75% of Billed Charges be Paid	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		33.5314448	-86.9902206	588.pdf
University of Alabama Hospital	Transplant	Birmingham	AL	Liver	Liver	Pediatric	Member's Choice		N/A	N/A		N/A	N/A	N/A			N/A	N/A	N/A	N/A	N/A	N/A		33.5314448	-86.9902206	588.pdf
University of Alabama Hospital	Transplant	Birmingham	AL	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	Bilateral: $120,020 \| Single: $107,024	20		85% of Billed Charges	85% of Billed Charges	90% of Billed Charges			Included in Case Rate	N/A	In no Event will less than 75% of Billed Charges be Paid	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		33.5314448	-86.9902206	589.pdf
University of Alabama Hospital	Transplant	Birmingham	AL	Lung	Lung	Pediatric	Member's Choice		N/A	N/A		N/A	N/A	N/A			N/A	N/A	N/A	N/A	N/A	N/A		33.5314448	-86.9902206	589.pdf
University of Alabama Hospital	Transplant	Birmingham	AL	Pancreas	Pancreas	Adult	Programs of Excellence		$70,529	14		85% of Billed Charges	85% of Billed Charges	90% of Billed Charges			Included in Case Rate	N/A	In no Event will less than 75% of Billed Charges be Paid	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		33.5314448	-86.9902206	590.pdf
University of Alabama Hospital	Transplant	Birmingham	AL	Pancreas	Pancreas	Pediatric	Programs of Excellence		$70,529	14		85% of Billed Charges	85% of Billed Charges	90% of Billed Charges			Included in Case Rate	N/A	In no Event will less than 75% of Billed Charges be Paid	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		33.5314448	-86.9902206	590.pdf
University of Arkansas for Medical Sciences (UAMS)	Transplant	Little Rock	AR	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$75,000	90	Begins on the First Day of Ablative Therapy and Ends at Discharge	N/A	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed $131,250, Payment will be the Transplant Case Rate Plus 60% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Inlier period has Expired	Ends 365 Days from the End of the Inlier Days		34.724126	-92.4079673	591.pdf
University of Arkansas for Medical Sciences (UAMS)	Transplant	Little Rock	AR	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$150,000	90	Begins on the First Day of Ablative Therapy and Ends at Discharge	N/A	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed $262,500, Payment will be the Transplant Case Rate Plus 60% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Inlier period has Expired	Ends 365 Days from the End of the Inlier Days		34.724126	-92.4079673	591.pdf
University of Arkansas for Medical Sciences (UAMS)	Transplant	Little Rock	AR	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$125,000	90	Begins on the First Day of Ablative Therapy and Ends at Discharge	N/A	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			If Billed Charges Exceed $218,750, Payment will be the Transplant Case Rate Plus 60% of the Excess charge	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Inlier period has Expired	Ends 365 Days from the End of the Inlier Days		34.724126	-92.4079673	591.pdf
University of Arkansas for Medical Sciences (UAMS)	Transplant	Little Rock	AR	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceQUALITY	1st Infusion: $75,000 \| 2nd Infusion: $56,250	1st Infusion: 30 \| 2nd Infusion: 60	Begins on the First Day of Ablative Therapy and Ends at Discharge	N/A	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			1st infustion $131,250 Then 60% of Charges 2nd infustion $98,438 Then 60% of Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Inlier period has Expired	Ends 365 Days from the End of the Inlier Days		34.724126	-92.4079673	591.pdf
University of Arkansas for Medical Sciences (UAMS)	Transplant	Little Rock	AR	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Adult	Programs of Excellence	PerformanceQUALITY	1st Infusion: $75,000 \| 2nd Infusion: $150,000	1st Infusion: 30 \| 2nd Infusion: 60	Begins on the First Day of Ablative Therapy and Ends at Discharge	N/A	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			1st infustion $131,250 Then 60% of Charges 2nd infustion $262,500 Then 60% of Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Inlier period has Expired	Ends 365 Days from the End of the Inlier Days		34.724126	-92.4079673	591.pdf
University of Arkansas for Medical Sciences (UAMS)	Transplant	Little Rock	AR	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	$70,000	14		$2,500 Med/Surg \| 2,500 ICU/CCU	80% of Billed Charges	70% of Billed Charges			Included in Case Rate	55% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One (1) Year from the End of the Transplant Phase	Ends 365 Days from the End of the Inlier Days and any Applicable Outlier Days		34.724126	-92.4079673	592.pdf
University of Arkansas for Medical Sciences (UAMS)	Transplant	Little Rock	AR	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	$150,000	30		$2,500 Med/Surg \| 2,500 ICU/CCU	80% of Billed Charges	70% of Billed Charges			Included in Case Rate	55% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One (1) Year from the End of the Transplant Phase	Ends 365 Days from the End of the Inlier Days and any Applicable Outlier Days		34.724126	-92.4079673	593.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $156,600 \| Professional: $22,140	N/A	N/A	N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges	Included in Case Rate	Reimbursed at the pre/post payable Rate			Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	594.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $189,000 \| Professional: $25,920	N/A	N/A	N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges	Included in Case Rate	Reimbursed at the pre/post payable Rate			Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	594.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $102,600 \| Professional: $21,060	N/A	N/A	N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges	Included in Case Rate	Reimbursed at the pre/post payable Rate			Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	594.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		Hospital: $102,600 \| Professional: $21,060	N/A	N/A	N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges	Included in Case Rate	Reimbursed at the pre/post payable Rate			Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	594.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		Hospital: $156,600 \| Professional: $22,140	N/A	N/A	N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges	Included in Case Rate	Reimbursed at the pre/post payable Rate			Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	594.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		Hospital: $189,000 \| Professional: $25,920	N/A	N/A	N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges	Included in Case Rate	Reimbursed at the pre/post payable Rate			Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		34.053691	-118.242766	594.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Heart	Heart	Adult	Programs of Excellence	PerformanceELITE	Hospital: $189,000 \| Professional: $44,280	N/A		N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			Included in Case Rate	Reimbursed at 33% of Billed Charges	Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	595.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Heart	Heart	Pediatric	Programs of Excellence		Hospital: $189,000 \| Professional: $44,280	N/A		N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			Included in Case Rate	Reimbursed at 33% of Billed Charges	Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	595.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Heart/Lung	Heart/Lung	Adult	Member's Choice		Hospital: 70% of Billed Charges \| Professional: 75% of Billed Charges	N/A		N/A		Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			100% of the Medicare Allowable	Reimbursed at 33% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	596.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor Hospital: $108,000 \| Cadaveric Donor Professional: $18,900 \| Living Donor Hospital: $108,000 \| Living Donor Professional: $21,060	N/A		N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			Included in Case Rate	Reimbursed at 33% of Billed Charges	Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	597.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Kidney	Kidney	Pediatric	Programs of Excellence		Cadaveric Donor Hospital: $108,000 \| Cadaveric Donor Professional: $18,900 \| Living Donor Hospital: $108,000 \| Living Donor Professional: $21,060	N/A		N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			Included in Case Rate	Reimbursed at 33% of Billed Charges	Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	597.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		Hospital: $259,200 \| Professional: $59,940	N/A		N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			Included in Case Rate	Reimbursed at 33% of Billed Charges	Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	598.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		Hospital: $297,000 \| Professional: $61,781	N/A		N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			Included in Case Rate	Reimbursed at 33% of Billed Charges	Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	599.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Kidney/Pancreas	Kidney/Pancreas	Pediatric	Member's Choice		Hospital: $297,000 \| Professional: $61,781	N/A		N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			Included in Case Rate	Reimbursed at 33% of Billed Charges	Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	599.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor Hospital: $189,000 \| Cadaveric Donor Professional: $49,140 \| Living Donor Hospital: $189,000 \| Living Donor Professional: $61,560	N/A		N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			Included in Case Rate	Reimbursed at 33% of Billed Charges	Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	600.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Liver	Liver	Pediatric	Member's Choice		Cadaveric Donor Hospital: $189,000 \| Cadaveric Donor Professional: $49,140 \| Living Donor Hospital: $189,000 \| Living Donor Professional: $61,560	N/A		N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			Included in Case Rate	Reimbursed at 33% of Billed Charges	Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	600.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	Hospital (Single): $189,000 \| Professional (Single): $48,600 \| Hospital (Bilateral): $297,000 \| Professional (Bilateral): $58,914	N/A		N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			Included in Case Rate	Reimbursed at 33% of Billed Charges	Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	601.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Lung	Lung	Pediatric	Member's Choice		Hospital (Single): $189,000 \| Professional (Single): $48,600 \| Hospital (Bilateral): $297,000 \| Professional (Bilateral): $58,914	N/A		N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			Included in Case Rate	Reimbursed at 33% of Billed Charges	Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	601.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Pancreas	Pancreas	Adult	Programs of Excellence		Hospital: $135,000 \| Professional: $30,240	N/A		N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			Included in Case Rate	Reimbursed at 33% of Billed Charges	Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	602.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Pancreas	Pancreas	Pediatric	Programs of Excellence		Hospital: $135,000 \| Professional: $30,240	N/A		N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			Included in Case Rate	Reimbursed at 33% of Billed Charges	Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	602.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Intestine	Intestine	Pediatric	Member's Choice		Hospital: $270,000 \| Professional: $88,020	N/A		N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			Included in Case Rate	Reimbursed at 33% of Billed Charges	Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	603.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Intestine	Intestine	Adult	Member's Choice		Hospital: $270,000 \| Professional: $88,020	N/A		N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			Included in Case Rate	Reimbursed at 33% of Billed Charges	Hospital 52.5% of Billed Charges Professional 70% of Billed Charges Anesthesia Services 80% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	603.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Multi-Organ	Multi-Organ	Pediatric	Member's Choice		Hospital: 70% of Billed Charges \| Professional: %75 of Billed Charges	N/A		N/A	N/A	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			100% of Hospital's Medicare Allowable Rate	Invoice Cost Plus 10%	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	604.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Multi-Organ	Multi-Organ	Adult	Member's Choice		Hospital: 70% of Billed Charges \| Professional: %75 of Billed Charges	N/A		N/A	N/A	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			100% of Hospital's Medicare Allowable Rate	Invoice Cost Plus 10%	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	604.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Islet	Islet	Adult	Member's Choice		Excluding Processing & Transport Hospital: 70% of Billed Charges \| Professional: 80% of Billed Charges \| Processing and Transport Hospital: 100% of Billed Charges \| Professional: 80% of Billed Charges	N/A		N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			Included in Case Rate	Reimbursed at 33% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	605.pdf
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Islet	Islet	Pediatric	Member's Choice		Excluding Processing & Transport Hospital: 70% of Billed Charges \| Professional: 80% of Billed Charges \| Processing and Transport Hospital: 100% of Billed Charges \| Professional: 80% of Billed Charges	N/A		N/A	90% of Billed Charges	Hospital and Professional: 75% of Billed Charges \| Anesthesia: 80% of Billed Charges			Included in Case Rate	Reimbursed at 33% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from the Date of Transplant		34.053691	-118.242766	605.pdf
University of California Irvine Medical Center	Transplant	Orange	CA	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice																	33.7873452	-117.8876498	875.pdf
University of California Irvine Medical Center	Transplant	Orange	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice																	33.7873452	-117.8876498	875.pdf
University of California Irvine Medical Center	Transplant	Orange	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice																	33.7873452	-117.8876498	875.pdf
University of California Irvine Medical Center	Transplant	Orange	CA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY																33.7873452	-117.8876498	876.pdf
University of California Irvine Medical Center	Transplant	Orange	CA	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice																	33.7873452	-117.8876498	877.pdf
University of California Irvine Medical Center	Transplant	Orange	CA	Pancreas	Pancreas	Adult	Programs of Excellence																	33.7873452	-117.8876498	878.pdf
University of California Irvine Medical Center	Cellular Immunotherapy	Orange	CA	Cellular Immunotherapy	Cellular Immunotherapy																			33.7873452	-117.8876498	879.pdf
University of California Irvine Medical Center	Transplant	Orange	CA	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates																	33.7873452	-117.8876498	880.pdf
University of California Irvine Medical Center	Transplant	Orange	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates																	33.7873452	-117.8876498	880.pdf
University of California Irvine Medical Center	Transplant	Orange	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Government Rates																	33.7873452	-117.8876498	880.pdf
University of California Irvine Medical Center	Transplant	Orange	CA	Kidney	Kidney	Adult	Government Rates																	33.7873452	-117.8876498	881.pdf
University of California Irvine Medical Center	Transplant	Orange	CA	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates																	33.7873452	-117.8876498	881.pdf
University of California Irvine Medical Center	Transplant	Orange	CA	Pancreas	Pancreas	Adult	Government Rates																	33.7873452	-117.8876498	881.pdf
University of California Irvine Medical Center (Government Rates)	Cellular Immunotherapy	Orange	CA	Cellular Immunotherapy	Cellular Immunotherapy																			33.7873452	-117.8876498	874.pdf
University of California San Diego Medical Center	Transplant	San Diego	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	138% of Medicare DRG with Applicable Pass Through	N/A		N/A	85% of Billed Charges	Hospital: Outpatient: 65% of Billed Charges Inpatient: $7,000 Med/Surg $9,000 ICU/CCU \| Professional: 65% of Billed Charges	Included in the Case Rate	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Inlier Days have Expired	Ends 365 Days from the End of the Inlier Days		32.8248175	-117.3891618	606.pdf
University of California San Diego Medical Center	Transplant	San Diego	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	138% of Medicare DRG with Applicable Pass Through	N/A		N/A	85% of Billed Charges	Hospital: Outpatient: 65% of Billed Charges Inpatient: $7,000 Med/Surg $9,000 ICU/CCU \| Professional: 65% of Billed Charges	Included in the Case Rate	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Inlier Days have Expired	Ends 365 Days from the End of the Inlier Days		32.8248175	-117.3891618	606.pdf
University of California San Diego Medical Center	Transplant	San Diego	CA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	138% of Medicare DRG with Applicable Pass Through	N/A		N/A	85% of Billed Charges	Hospital: Outpatient: 65% of Billed Charges Inpatient: $7,000 Med/Surg $9,000 ICU/CCU \| Professional: 65% of Billed Charges	Included in the Case Rate	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Inlier Days have Expired	Ends 365 Days from the End of the Inlier Days		32.8248175	-117.3891618	606.pdf
University of California San Diego Medical Center	Transplant	San Diego	CA	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Programs of Excellence	PerformanceQUALITY	138% of Medicare DRG with Applicable Pass Through	N/A		N/A	85% of Billed Charges	Hospital: Outpatient: 65% of Billed Charges Inpatient: $7,000 Med/Surg $9,000 ICU/CCU \| Professional: 65% of Billed Charges	Included in the Case Rate	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Inlier Days have Expired	Ends 365 Days from the End of the Inlier Days		32.8248175	-117.3891618	606.pdf
University of California San Diego Medical Center	Transplant	San Diego	CA	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceQUALITY	138% of Medicare DRG with Applicable Pass Through	N/A		N/A	85% of Billed Charges	Hospital: Outpatient: 65% of Billed Charges Inpatient: $7,000 Med/Surg $9,000 ICU/CCU \| Professional: 65% of Billed Charges	Included in the Case Rate	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Inlier Days have Expired	Ends 365 Days from the End of the Inlier Days		32.8248175	-117.3891618	606.pdf
University of California San Diego Medical Center	Transplant	San Diego	CA	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Adult	Programs of Excellence	PerformanceQUALITY	138% of Medicare DRG with Applicable Pass Through	N/A		N/A	85% of Billed Charges	Hospital: Outpatient: 65% of Billed Charges Inpatient: $7,000 Med/Surg $9,000 ICU/CCU \| Professional: 65% of Billed Charges	Included in the Case Rate	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Inlier Days have Expired	Ends 365 Days from the End of the Inlier Days		32.8248175	-117.3891618	606.pdf
University of California San Diego Medical Center	Transplant	San Diego	CA	Heart	Heart	Adult	Programs of Excellence	PerformanceELITE	138% of Medicare DRG with Applicable Pass Through	N/A		N/A	85% of Billed Charges	Hospital: Outpatient: 65% of Billed Charges Inpatient: $7,000 Med/Surg $9,000 ICU/CCU \| Professional: 65% of Billed Charges			100% of D-4 Report	Reimbursed at 45% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when the Inlier Days have Expired	Ends 365 Days from the End of the Inlier Days		32.8248175	-117.3891618	607.pdf
University of California San Diego Medical Center	Transplant	San Diego	CA	Heart/Lung	Heart/Lung	Adult	Member's Choice		138% of Medicare DRG with Applicable Pass Through	N/A		N/A	85% of Billed Charges	Hospital: Outpatient: 65% of Billed Charges Inpatient: $7,000 Med/Surg $9,000 ICU/CCU \| Professional: 65% of Billed Charges			100% of D-4 Report	Reimbursed at 45% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when the Inlier Days have Expired	Ends 365 Days from the End of the Inlier Days		32.8248175	-117.3891618	607.pdf
University of California San Diego Medical Center	Transplant	San Diego	CA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	138% of Medicare DRG with Applicable Pass Through	N/A		N/A	85% of Billed Charges	Hospital: Outpatient: 65% of Billed Charges Inpatient: $7,000 Med/Surg $9,000 ICU/CCU \| Professional: 65% of Billed Charges			100% of D-4 Report	Reimbursed at 45% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when the Inlier Days have Expired	Ends 365 Days from the End of the Inlier Days		32.8248175	-117.3891618	607.pdf
University of California San Diego Medical Center	Transplant	San Diego	CA	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	138% of Medicare DRG with Applicable Pass Through	N/A		N/A	85% of Billed Charges	Hospital: Outpatient: 65% of Billed Charges Inpatient: $7,000 Med/Surg $9,000 ICU/CCU \| Professional: 65% of Billed Charges			100% of D-4 Report	Reimbursed at 45% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when the Inlier Days have Expired	Ends 365 Days from the End of the Inlier Days		32.8248175	-117.3891618	607.pdf
University of California San Diego Medical Center	Transplant	San Diego	CA	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	138% of Medicare DRG with Applicable Pass Through	N/A		N/A	85% of Billed Charges	Hospital: Outpatient: 65% of Billed Charges Inpatient: $7,000 Med/Surg $9,000 ICU/CCU \| Professional: 65% of Billed Charges			100% of D-4 Report	Reimbursed at 45% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when the Inlier Days have Expired	Ends 365 Days from the End of the Inlier Days		32.8248175	-117.3891618	607.pdf
University of California San Diego Medical Center	Transplant	San Diego	CA	Multi-Organ	Multi-Organ	Adult	Member's Choice		138% of Medicare DRG with Applicable Pass Through	N/A		N/A	85% of Billed Charges	Hospital: Outpatient: 65% of Billed Charges Inpatient: $7,000 Med/Surg $9,000 ICU/CCU \| Professional: 65% of Billed Charges			100% of D-4 Report	Reimbursed at 45% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when the Inlier Days have Expired	Ends 365 Days from the End of the Inlier Days		32.8248175	-117.3891618	607.pdf
University of California San Diego Medical Center	Cellular Immunotherapy	San Diego	CA	Cellular Immunotherapy	Cellular Immunotherapy				Charges $0 - $500,000 Pay at 65% \| Charges $500,001 - $1,000,000 Pay at 60% \| Charges $1,000,001 and Above Pay at 55% \| Drug Cost: 100% of Invoice Cost	N/A		N/A	N/A	70% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends One (1) Year from Discharge		32.8244741	-117.249404	615.pdf
University of California San Diego Medical Center	Destination VAD	San Diego	CA	Destination VAD	Destination VAD				Surgical Event: 60% of Billed Charges	N/A		Hospital: $6,000 Per Diem \| Professional: 170% Medicare Fee Schedule	N/A	65% of Billed Charges \| VAD Maintenance & Supplies: 105% of Invoice Cost				45% of Billed Charges	N/A	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		32.8244741	-117.249404	616.pdf
University of California San Diego Medical Center	Bariatric	San Diego	CA	Bariatric	Bariatric				Gastric Banding: $17,000 \| Gastric Bypass: $22,000 \| Gastric Sleeve: $17,000	2		$5,250	80% of Billed Charges	65% of Billed Charges					N/A	Begins at Evaluation and Ends on the Day of Surgery	Begins on the Day of Surgery and Ends when Inlier Days and Applicable Outlier Days have Expired	Begins when Inlier Days and Applicable Outlier Days have Expired and Ends One Year from Discharge		32.8244741	-117.249404	617.pdf
University of California San Diego Medical Center	Cancer	San Diego	CA	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															32.8244741	-117.249404	618.pdf
University of California San Diego Medical Center (Applies to Medicare Advantage and Medicaid with Pre-Approval)	Transplant	San Diego	CA	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates		110% of Medicare DRG with Applicable Pass Through	N/A	N/A	N/A	N/A	110% of Medicare DRG with Applicable Pass Through	100% of Invoice Cost	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on Day of Admission for Ablative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		32.8244741	-117.249404	619.pdf
University of California San Diego Medical Center (Applies to Medicare Advantage and Medicaid with Pre-Approval)	Transplant	San Diego	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates		110% of Medicare DRG with Applicable Pass Through	N/A	N/A	N/A	N/A	110% of Medicare DRG with Applicable Pass Through	100% of Invoice Cost	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on Day of Admission for Ablative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		32.8244741	-117.249404	619.pdf
University of California San Diego Medical Center (Applies to Medicare Advantage and Medicaid with Pre-Approval)	Transplant	San Diego	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Government Rates		110% of Medicare DRG with Applicable Pass Through	N/A	N/A	N/A	N/A	110% of Medicare DRG with Applicable Pass Through	100% of Invoice Cost	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on Day of Admission for Ablative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		32.8244741	-117.249404	619.pdf
University of California San Diego Medical Center (Applies to Medicare Advantage and Medicaid with Pre-Approval)	Transplant	San Diego	CA	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Government Rates		110% of Medicare DRG with Applicable Pass Through	N/A	N/A	N/A	N/A	110% of Medicare DRG with Applicable Pass Through	100% of Invoice Cost	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on Day of Admission for Ablative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		32.8244741	-117.249404	619.pdf
University of California San Diego Medical Center (Applies to Medicare Advantage and Medicaid with Pre-Approval)	Transplant	San Diego	CA	Heart	Heart	Adult	Government Rates		110% of Medicare DRG with Applicable Pass Through	N/A		N/A	N/A	110% of Medicare DRG with Applicable Pass Through			100% of Invoice Cost	45% of Billed Charges	N/A	Begins at Evaluation	Begins on Day of Admission for Ablative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		32.8244741	-117.249404	620.pdf
University of California San Diego Medical Center (Applies to Medicare Advantage and Medicaid with Pre-Approval)	Transplant	San Diego	CA	Heart/Lung	Heart/Lung	Adult	Government Rates		110% of Medicare DRG with Applicable Pass Through	N/A		N/A	N/A	110% of Medicare DRG with Applicable Pass Through			100% of Invoice Cost	45% of Billed Charges	N/A	Begins at Evaluation	Begins on Day of Admission for Ablative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		32.8244741	-117.249404	621.pdf
University of California San Diego Medical Center (Applies to Medicare Advantage and Medicaid with Pre-Approval)	Transplant	San Diego	CA	Kidney	Kidney	Adult	Government Rates		110% of Medicare DRG with Applicable Pass Through	N/A		N/A	N/A	110% of Medicare DRG with Applicable Pass Through			100% of Invoice Cost	45% of Billed Charges	N/A	Begins at Evaluation	Begins on Day of Admission for Ablative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		32.8244741	-117.249404	622.pdf
University of California San Diego Medical Center (Applies to Medicare Advantage and Medicaid with Pre-Approval)	Transplant	San Diego	CA	Liver	Liver	Adult	Government Rates		110% of Medicare DRG with Applicable Pass Through	N/A		N/A	N/A	110% of Medicare DRG with Applicable Pass Through			100% of Invoice Cost	45% of Billed Charges	N/A	Begins at Evaluation	Begins on Day of Admission for Ablative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		32.8244741	-117.249404	624.pdf
University of California San Diego Medical Center (Applies to Medicare Advantage and Medicaid with Pre-Approval)	Transplant	San Diego	CA	Lung	Lung	Adult	Government Rates		110% of Medicare DRG with Applicable Pass Through	N/A		N/A	N/A	110% of Medicare DRG with Applicable Pass Through			100% of Invoice Cost	45% of Billed Charges	N/A	Begins at Evaluation	Begins on Day of Admission for Ablative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		32.8244741	-117.249404	625.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $123,000 \| Professional: $22,000	N/A	N/A	N/A	90% of Billed Charges	70% of Billed Charges	Included in the Case Rate	Reimbursed at Invoice Cost Plus 5%			If Billed Charges Exceed $216,000 (hospital) or $36,000 (professional), Payment will be the Transplant Case Rate Plus 55% of the Excess Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends at Discharge	Ends One Year from Discharge		37.7577627	-122.4726194	627.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $135,000 \| Professional: $25,000	N/A	N/A	N/A	90% of Billed Charges	70% of Billed Charges	Included in the Case Rate	Reimbursed at Invoice Cost Plus 5%			If Billed Charges Exceed $237,000 (hospital) or $41,000 (professional), Payment will be the Transplant Case Rate Plus 55% of the Excess Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends at Discharge	Ends One Year from Discharge		37.7577627	-122.4726194	627.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $80,000 \| Professional: $15,000	N/A	N/A	N/A	90% of Billed Charges	70% of Billed Charges	Included in the Case Rate	Reimbursed at Invoice Cost Plus 5%			If Billed Charges Exceed $140,000 (hospital) or $25,000 (professional), Payment will be the Transplant Case Rate Plus 55% of the Excess Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends at Discharge	Ends One Year from Discharge		37.7577627	-122.4726194	627.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $135,000 \| Professional: $25,000	N/A	N/A	N/A	90% of Billed Charges	70% of Billed Charges	Included in the Case Rate	Reimbursed at Invoice Cost Plus 5%			If Billed Charges Exceed $225,000 (hospital) or $41,000 (professional), Payment will be the Transplant Case Rate Plus 55% of the Excess Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends at Discharge	Ends One Year from Discharge		37.7577627	-122.4726194	627.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceQUALITY	1st Transplant: $78,000 Hospital $15,000 Professional \| 2nd Transplant: $78,000 Professional $15,000 Professional	N/A	N/A	N/A	90% of Billed Charges	70% of Billed Charges	Included in the Case Rate	Reimbursed at Invoice Cost Plus 5%			For each Transplant, if Billed Charges Exceed $128,000 (hospital) or $25,000 (professional), Payment will be the Transplant Case Rate Plus 55% of the Excess Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends at Discharge	Ends One Year from Discharge		37.7577627	-122.4726194	627.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Adult	Programs of Excellence	PerformanceQUALITY	1st Transplant: $80,000 Hospital $15,000 Professional \| 2nd Transplant: $78,000 Professional $15,000 Professional	N/A	N/A	N/A	90% of Billed Charges	70% of Billed Charges	Included in the Case Rate	Reimbursed at Invoice Cost Plus 5%			If Billed Charges Exceed $130,000 (hospital 1st transplant) or $25,000 (professional 1st transplant), or $128,000 (hospital 2nd transplant) or $25,000 (professional 2nd transplant) Payment will be the Transplant Case Rate Plus 55% of the Excess Charges	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends at Discharge	Ends One Year from Discharge		37.7577627	-122.4726194	627.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A			N/A	N/A	N/A	Ends One Year from Discharge		37.7577627	-122.4726194	627.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A			N/A	N/A	N/A	Ends One Year from Discharge		37.7577627	-122.4726194	627.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A			N/A	N/A	N/A	Ends One Year from Discharge		37.7577627	-122.4726194	627.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $115,000 \| Professional: $30,000	N/A		N/A	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	If Billed Charges Exceed $202,000 (hospital) or $50,000 (professional), Payment will be the Transplant Case Rate Plus 55% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One Year from Discharge		37.7577627	-122.4726194	628.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Intestine	Intestine	Adult	Member's Choice		Hospital: $170,000 \| Professional: $42,000	N/A		N/A	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	If Billed Charges Exceed $298,000 (hospital) or $70,000 (professional), Payment will be the Transplant Case Rate Plus 55% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One Year from Discharge		37.7577627	-122.4726194	629.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor Hospital: $68,000 \| Cadaveric Donor Professional: $15,000 \| Living Donor Hospital: $60,000 \| Living Donor Professional: $20,000	N/A		N/A	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	If Cadaveric Billed Charges Exceed $120,000 (hospital) or $25,000 (professional), Payment will be the Transplant Case Rate Plus 55% of the Excess Charges If Living Billed Charges Exceed $106,000 (hospital) or $33,000 (professional), Payment will be the Transplant Case Rate Plus 55% of Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One Year from Discharge		37.7577627	-122.4726194	630.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Kidney	Kidney	Pediatric	Programs of Excellence		N/A	N/A		N/A	N/A	N/A			N/A	N/A	N/A	N/A	N/A	Ends One Year from Discharge		37.7577627	-122.4726194	630.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $112,000 \| Professional: $28,000	N/A		N/A	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	If Billed Charges Exceed $197,000 (hospital) or $46,000 (professional), Payment will be the Transplant Case Rate Plus 55% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One Year from Discharge		37.7577627	-122.4726194	631.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor Hospital: $114,000 \| Cadaveric Donor Professional: $34,000 \| Living Donor Hospital: $110,000 \| Living Donor Professional: $39,000	N/A		N/A	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	If Cadaveric Billed Charges Exceed $200,000 (hospital) or $56,000 (professional), Payment will be the Transplant Case Rate Plus 55% of the Excess Charges If Living Billed Charges Exceed $193,000 (hospital) or $65,000 (professional), Payment will be the Transplant Case Rate Plus 55% of Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One Year from Discharge		37.7577627	-122.4726194	632.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Liver	Liver	Pediatric	Programs of Excellence		N/A	N/A		N/A	N/A	N/A			N/A	N/A	N/A	N/A	N/A	Ends One Year from Discharge		37.7577627	-122.4726194	632.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Lung	Lung	Adult	Programs of Excellence	PerformanceELITE	Single Hospital: $130,000 \| Single Professional: $34,000 \| Bilateral Hospital: $145,000 \| Bilateral Professional: $36,000	N/A		N/A	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	If single Billed Charges Exceed $228,000 (hospital) or $56,000 (professional), Payment will be the Transplant Case Rate Plus 55% of the Excess Charges If bilateral Billed Charges Exceed $254,000 (hospital) or $60,000 (professional), Payment will be the Transplant Case Rate Plus 55% of Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One Year from Discharge		37.7577627	-122.4726194	633.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Pancreas	Pancreas	Adult	Programs of Excellence		Cadaveric Donor Hospital: $90,000 \| Cadaveric Donor Professional: $24,000	N/A		N/A	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	If Cadaveric Billed Charges Exceed $158,000 (hospital) or $40,000 (professional), Payment will be the Transplant Case Rate Plus 55% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One Year from Discharge		37.7577627	-122.4726194	634.pdf
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Heart/Lung	Heart/Lung	Adult	Member's Choice		Cadaveric Donor Hospital: $125,000 \| Cadaveric Donor Professional: $35,000	N/A		N/A	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	If Cadaveric Billed Charges Exceed $220,000 (hospital) or $58,000 (professional), Payment will be the Transplant Case Rate Plus 55% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One Year from Discharge		37.7577627	-122.4726194	635.pdf
University of California San Francisco Medical Center	Cancer	San Francisco	CA	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															37.7576948	-122.4727051	636.pdf
University of Chicago Medical Center	Transplant	Chicago	IL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$133,800	42		55% of Billed Charges	90% of Billed Charges	72% of Billed Charges	Included in Case Rate	55% of Billed Charges			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.8339037	-87.8720468	637.pdf
University of Chicago Medical Center	Transplant	Chicago	IL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$133,800	42		55% of Billed Charges	90% of Billed Charges	72% of Billed Charges	Included in Case Rate	55% of Billed Charges			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.8339037	-87.8720468	637.pdf
University of Chicago Medical Center	Transplant	Chicago	IL	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$91,800	32		55% of Billed Charges	90% of Billed Charges	72% of Billed Charges	Included in Case Rate	55% of Billed Charges			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.8339037	-87.8720468	637.pdf
University of Chicago Medical Center	Transplant	Chicago	IL	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$118,000	25		55% of Billed Charges	90% of Billed Charges	72% of Billed Charges			Included in Case Rate	55% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	638.pdf
University of Chicago Medical Center	Destination VAD	Chicago	IL	Destination VAD	Destination VAD				Surgical Event: 72% of Billed Charges	N/A		Inpatient Days (Non-Surgical): $2,400 Med/Surg \| $2,600 ICU/CCU	Inpatient Days: 90% of Billed Charges	72% of Billed Charges				55% of Billed Charges	50% of Billed Charges	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		41.8336474	-87.8723887	638.pdf
University of Chicago Medical Center	Transplant	Chicago	IL	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$53,000	15		55% of Billed Charges	90% of Billed Charges	72% of Billed Charges			Included in Case Rate	55% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	639.pdf
University of Chicago Medical Center	Transplant	Chicago	IL	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	$89,880	20		55% of Billed Charges	90% of Billed Charges	72% of Billed Charges			Included in Case Rate	55% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	640.pdf
University of Chicago Medical Center	Transplant	Chicago	IL	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	$148,000	33		55% of Billed Charges	90% of Billed Charges	72% of Billed Charges			Included in Case Rate	55% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	641.pdf
University of Chicago Medical Center	Transplant	Chicago	IL	Lung	Lung	Adult	Member's Choice		Single or Bilateral: $150,000	20		55% of Billed Charges	90% of Billed Charges	72% of Billed Charges			Included in Case Rate	55% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	642.pdf
University of Chicago Medical Center	Transplant	Chicago	IL	Pancreas	Pancreas	Adult	Programs of Excellence		$72,000	20		55% of Billed Charges	90% of Billed Charges	72% of Billed Charges			Included in Case Rate	55% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	643.pdf
University of Chicago Medical Center	Transplant	Chicago	IL	Multi-Organ	Multi-Organ	Adult	Member's Choice		65% of Billed Charges	N/A			N/A	72% of Billed Charges			Included in Case Rate	55% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.8339037	-87.8720468	644.pdf
University of Chicago Medical Center	Bariatric	Chicago	IL	Bariatric	Bariatric				Duodenal Switch: $25,000 \| Gastric Banding: $15,000 \| Gastric Bypass: $25,000 \| Gastric Sleeve: $11,000	Duodenal Switch: 3 \| Gastric Banding: 2 \| Gastric Bypass: 3 \| Gastric Sleeve: 2		$2,500	80% of Billed Charges	72% of Billed Charges					62% of Billed Charges	Begins at Evaluation	Begins on the Day of Surgery and Ends when the Number of Inlier Days and Applicable Outlier Days have Expired	Begins at Discharge and Ends One (1) Year Later		41.8336474	-87.8723887	645.pdf
University of Cincinnati Medical Center	Transplant	Cincinnati	OH	Tandem (Auto-to-Auto)	Tandem Auto to Auto	Adult	Member's Choice		Hospital: $251,942 \| Professional: 75% of Billed Charges	1st: 25 \| 2nd: 25		$3,462 Med/Surg \| $4,328 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins at Evaluation	Ends One (1) Year from Discharge		39.136319	-84.6106124	646.pdf
University of Cincinnati Medical Center	Transplant	Cincinnati	OH	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		Hospital: $217,896 \| Professional: 75% of Billed Charges	30		$3,462 Med/Surg \| $4,328 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate		Reimbursed at 75% of Billed Charges	N/A	Begins at Evaluation	Begins on the First Day of Ablative Therapy and Ends when the Inlier Days have Expired	Ends One (1) Year from Discharge		39.136319	-84.6106124	646.pdf
University of Cincinnati Medical Center	Transplant	Cincinnati	OH	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		Hospital: $306,417 \| Professional: 75% of Billed Charges	30		$3,462 Med/Surg \| $4,328 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate		Reimbursed at 75% of Billed Charges	N/A	Begins at Evaluation	Begins on the First Day of Ablative Therapy and Ends when the Inlier Days have Expired	Ends One (1) Year from Discharge		39.136319	-84.6106124	646.pdf
University of Cincinnati Medical Center	Transplant	Cincinnati	OH	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		Hospital: $142,995 \| Professional: 75% of Billed Charges	30		$3,462 Med/Surg \| $4,328 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate		Reimbursed at 75% of Billed Charges	N/A	Begins at Evaluation	Begins at Evaluation	Ends One (1) Year from Discharge		39.136319	-84.6106124	646.pdf
University of Cincinnati Medical Center	Transplant	Cincinnati	OH	Heart	Heart	Adult	Member's Choice		Hospital: $339,101 \| Professional: 75% of Billed Charges	25		$3,462 Med/Surg \| $4,328 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 75% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.136319	-84.6106124	647.pdf
University of Cincinnati Medical Center	Destination VAD	Cincinnati	OH	Destination VAD	Destination VAD				Surgical Event: 65% of Billed Charges	N/A		N/A	N/A	75% of Billed Charges				75% of Billed Charges	N/A	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		39.136319	-84.6106124	647.pdf
University of Cincinnati Medical Center	Transplant	Cincinnati	OH	Islet	Islet	Adult	Member's Choice		Hospital: 70% of Billed Charges \| Professional: 75% of Billed Charges	N/A		N/A	90% of Billed Charges	75% of Billed Charges			N/A	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.136319	-84.6106124	648.pdf
University of Cincinnati Medical Center	Transplant	Cincinnati	OH	Pancreas	Pancreas	Adult	Programs of Excellence		Hospital: $147,227 \| Professional: 75% of Billed Charges	15		$3,462 Med/Surg \| $4,328 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 75% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.136319	-84.6106124	649.pdf
University of Cincinnati Medical Center	Transplant	Cincinnati	OH	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor, Hospital: $137,256 \| Cadaveric Donor, Professional: 75% of Billed Charges \| Living Donor, Hospital: $105,942 \| Living Donor, Professional: 75% of Billed Charges	12		$3,462 Med/Surg \| $4,328 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 75% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.136319	-84.6106124	650.pdf
University of Cincinnati Medical Center	Transplant	Cincinnati	OH	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $170,356 \| Professional: 75% of Billed Charges	15		$3,462 Med/Surg \| $4,328 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 75% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.136319	-84.6106124	651.pdf
University of Cincinnati Medical Center	Transplant	Cincinnati	OH	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor, Hospital: $272,371 \| Cadaveric Donor, Professional: 75% of Billed Charges \| Living Donor, Hospital: $324,056 \| Living Donor, Professional: 75% of Billed Charges	25		$3,462 Med/Surg \| $4,328 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 75% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		39.136319	-84.6106124	652.pdf
University of Cincinnati Medical Center	Bariatric	Cincinnati	OH	Bariatric	Bariatric				Duodenal Switch: $16,000 \| Gastric Banding: $15,000 \| Gastric Bypass: $18,000 \| Gastric Sleeve: $11,000	Duodenal Switch: 3 \| Gastric Banding: 2 \| Gastric Bypass: 3 \| Gastric Sleeve: 2		$2,500	80% of Billed Charges	70% of Billed Charges					N/A	Begins at Evaluation	Begins on the Day of Surgery and Ends when the Number of Inlier Days and Applicable Outlier Days have Expired	Begins at Discharge and Ends One (1) Year Later		39.136319	-84.6106124	653.pdf
University of Colorado Hospital	Transplant	Aurora	CO	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	$145,000	30	Provisions the same as Inpatient	$4,500 Med/Surg \| $4,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			55% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		39.6890151	-104.8269166	654.pdf
University of Colorado Hospital	Transplant	Aurora	CO	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	$180,000	30	Provisions the same as Inpatient	$4,50000 Med/Surg \| $4,50000 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			55% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		39.6890151	-104.8269166	654.pdf
University of Colorado Hospital	Transplant	Aurora	CO	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	Auto PSC: $120,000 \| Auto BMT: $140,000	30	Provisions the same as Inpatient	$4,500 Med/Surg \| $4,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			55% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		39.6890151	-104.8269166	654.pdf
University of Colorado Hospital	Transplant	Aurora	CO	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$155,000	24		$4,500 Med/Surg \| $4,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	If Inserted During Pre/Post Transplant: Reimbursed at 75% of Billed Charges \| If Inserted During the Transplant Phase: Included in the Case Rate	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		39.6890151	-104.8269166	655.pdf
University of Colorado Hospital	Transplant	Aurora	CO	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$68,000	14		$3,500 Med/Surg \| $3,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from from the Inlier Days and any applicable Outlier Days		39.6890151	-104.8269166	656.pdf
University of Colorado Hospital	Transplant	Aurora	CO	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	$117,500	14		$4,500 Med/Surg \| $4,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		39.6890151	-104.8269166	657.pdf
University of Colorado Hospital	Transplant	Aurora	CO	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor: $168,000 \| Living Donor: $176,500	18		$3,500 Med/Surg \| $3,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		39.6890151	-104.8269166	658.pdf
University of Colorado Hospital	Transplant	Aurora	CO	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	Single: $165,000 \| Bilateral: $180,000	20		$4,500 Med/Surg \| $4,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		39.6890151	-104.8269166	659.pdf
University of Colorado Hospital	Transplant	Aurora	CO	Pancreas	Pancreas	Adult	Programs of Excellence		$89,000	14		$4,500 Med/Surg \| $4,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		39.6890151	-104.8269166	660.pdf
University of Colorado Hospital	Transplant	Aurora	CO	Multi-Organ	Multi-Organ	Adult	Member's Choice		100% of More Expensive Organ, Plus 50% of Second Organ	Greater of the Two Applicable Organ Inlier Days		$4,500 Med/Surg \| $4,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends (1) One Year from Discharge		39.6890151	-104.8269166	661.pdf
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	$140,000	32		$4,000 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.6471118	-91.5743828	662.pdf
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	$177,000	35		$4,000 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.6471118	-91.5743828	662.pdf
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	$112,000	28		$4,000 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.6471118	-91.5743828	662.pdf
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Member's Choice		$140,000	32		$4,000 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.6471118	-91.5743828	662.pdf
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Member's Choice		$170,000	35		$4,000 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.6471118	-91.5743828	662.pdf
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Blood/Marrow (Autologous)	Autologous	Pediatric	Member's Choice		$115,000	28		$4,000 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		41.6471118	-91.5743828	662.pdf
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Heart	Heart	Adult	Member's Choice		$158,000	18		$4,000 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	60% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.6471118	-91.5743828	663.pdf
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Heart	Heart	Pediatric	Member's Choice		$158,000	18		$4,000 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	60% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.6471118	-91.5743828	663.pdf
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor: $75,000 \| Living Donor: $73,000	7		$4,000 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	60% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.6471118	-91.5743828	664.pdf
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Kidney	Kidney	Pediatric	Member's Choice		Cadaveric Donor: $75,000 \| Living Donor: $73,000	7		$4,000 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	60% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.6471118	-91.5743828	664.pdf
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$125,000	9		$4,000 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	60% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.6471118	-91.5743828	665.pdf
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Kidney/Pancreas	Kidney/Pancreas	Pediatric	Member's Choice		$125,000	9		$4,000 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	60% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.6471118	-91.5743828	665.pdf
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Liver	Liver	Adult	Member's Choice		Cadaveric Donor: $158,000 \| Living Donor: $ 165,000	18 \| 20		$4,000 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	60% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.6471118	-91.5743828	666.pdf
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Liver	Liver	Pediatric	Member's Choice		Cadaveric Donor: $158,000 \| Living Donor: $ 165,000	18 \| 20		$4,000 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	60% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.6471118	-91.5743828	666.pdf
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Pancreas	Pancreas	Adult	Member's Choice		$90,000	7		$4,000 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	60% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		41.6471118	-91.5743828	667.pdf
University of Iowa Hospitals and Clinics	Cellular Immunotherapy	Iowa City	IA	Cellular Immunotherapy	Cellular Immunotherapy				Charges $0 - $1,000,000 Pay at 65% \| Charges $1,000,000 & Above Pay at 60% \| Drug Cost: 110% of Wholesale Acquisition Cost (WAC)	N/A		N/A	N/A	70% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends 365 Days from Discharge		41.6470476	-91.5744685	668.pdf
University of Iowa Hospitals and Clinics	Cancer	Iowa City	IA	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															41.6470476	-91.5744685	669.pdf
University of Kansas Hospital	Transplant	Kansas City	KS	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	$185,000	30		Non-ICU: $3,500 \| ICU: $5,000 \| Outpatient: 70% of Billed Charges	70% of Billed Charges	60% of Billed Charges	Charges Included in Transplant Case Rate	Charges Included in Transplant Case Rate			If Charges Exceed $560,606, Payment will be the Case Rate, Plus 70% of the Excess Charges	Begins at Evaluation	Begins on the Day of Admittance for Preparative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		39.1232139	-94.818637	670.pdf
University of Kansas Hospital	Transplant	Kansas City	KS	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	$285,000	30		Non-ICU: $3,500 \| ICU: $5,000 \| Outpatient: 70% of Billed Charges	70% of Billed Charges	60% of Billed Charges	Charges Included in Transplant Case Rate	Charges Included in Transplant Case Rate			If Charges Exceed $863,636, Payment will be the Case Rate, Plus 70% of the Excess Charges	Begins at Evaluation	Begins on the Day of Admittance for Preparative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		39.1232139	-94.818637	670.pdf
University of Kansas Hospital	Transplant	Kansas City	KS	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	$300,000	30		Non-ICU: $3,500 \| ICU: $5,000 \| Outpatient: 70% of Billed Charges	70% of Billed Charges	60% of Billed Charges	Charges Included in Transplant Case Rate	Charges Included in Transplant Case Rate			If Charges Exceed $909,091, Payment will be the Case Rate, Plus 70% of the Excess Charges	Begins at Evaluation	Begins on the Day of Admittance for Preparative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		39.1232139	-94.818637	670.pdf
University of Kansas Hospital	Transplant	Kansas City	KS	Heart	Heart	Adult	Programs of Excellence	PerformanceELITE	$275,000	18		Non-ICU: $3,500 \| ICU: $5,000 \| Outpatient: 70% of Billed Charges	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	100% of Invoice Cost	If Charges Exceed $833,333, Payment will be the Case Rate, Plus 70% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		39.1232139	-94.818637	671.pdf
University of Kansas Hospital	Destination VAD	Kansas City	KS	Destination VAD	Destination VAD				Sugical Event: 55% of Billed Charges \|Inpatient Per Diem Hospital: $5,000 \|Inpatient Per Diem Professional: $5,000 \|Outpatient: 60% of Billed Charges				70% of Billed Charges					Device: 100% of Invoice Cost \| Maintenance 105% of Invoice Cost	N/A	Begins at Evaluation	Surgical Event Occurs on the Day of VAD Insertion. Inpatient Per Diems will not Apply to Inpatient Care Provided on the day of Surgical Event	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		39.1232139	-94.818637	671.pdf
University of Kansas Hospital	Transplant	Kansas City	KS	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$150,000	12		Non-ICU: $3,500 \| ICU: $5,000 \| Outpatient: 70% of Billed Charges	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	100% of Invoice Cost	If Charges Exceed $454,545, Payment will be the Case Rate, Plus 70% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		39.1232139	-94.818637	672.pdf
University of Kansas Hospital	Transplant	Kansas City	KS	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$185,000	16		Non-ICU: $3,500 \| ICU: $5,000 \| Outpatient: 70% of Billed Charges	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	100% of Invoice Cost	If Charges Exceed $560,606, Payment will be the Case Rate, Plus 70% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		39.1232139	-94.818637	673.pdf
University of Kansas Hospital	Transplant	Kansas City	KS	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	$180,000	23		Non-ICU: $3,500 \| ICU: $5,000 \| Outpatient: 70% of Billed Charges	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	100% of Invoice Cost	If Charges Exceed $545,455, Payment will be the Case Rate, Plus 70% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		39.1232139	-94.818637	674.pdf
University of Kansas Hospital	Cellular Immunotherapy	Kansas City	KS	Cellular Immunotherapy	Cellular Immunotherapy				60% of Billed Charges \| Drug Cost: 100% of Wholesale Acquisition Cost (WAC)	N/A		N/A	N/A	60% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends One (1) Year from Discharge		39.1232139	-94.818637	675.pdf
University of Kansas Hospital	Transplant	Kansas City	KS	Pancreas	Pancreas	Adult	Programs of Excellence		$125,000	12		Non-ICU: $3,500 \| ICU: $5,000 \| Outpatient: 70% of Billed Charges	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	100% of Invoice Cost	If Charges Exceed $378,788, Payment will be the Case Rate, Plus 70% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		39.1232139	-94.818637	676.pdf
University of Kansas Hospital	Transplant	Kansas City	KS	Multi-Organ	Pancreas	Adult	Member's Choice		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	Equal to number of days of higher cost organ		Non-ICU: $3,500 \| ICU: $5,000 \| Outpatient: 70% of Billed Charges	70% of Billed Charges	60% of Billed Charges			Included in Case Rate	100% of Invoice Cost	If Charges Exceed 100% of Higher Cost Organ Threshold Plus 50% of Lower Cost Organ Threshold, Payment will be the Case Rate, Plus 70% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		39.1232139	-94.818637	677.pdf
University of Kansas Hospital	Transplant	Kansas City	KS	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates		107% of Medicare Allowable	N/A	N/A	N/A	N/A	107% of Medicare Allowable	Charges Included in Transplant Case Rate	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Admittance for Preparative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		39.1232139	-94.818637	678.pdf
University of Kansas Hospital	Transplant	Kansas City	KS	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates		107% of Medicare Allowable	N/A	N/A	N/A	N/A	107% of Medicare Allowable	Charges Included in Transplant Case Rate	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Admittance for Preparative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		39.1232139	-94.818637	678.pdf
University of Kansas Hospital	Transplant	Kansas City	KS	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Government Rates		107% of Medicare Allowable	N/A	N/A	N/A	N/A	107% of Medicare Allowable	Charges Included in Transplant Case Rate	100% of Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Admittance for Preparative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		39.1232139	-94.818637	678.pdf
University of Kansas Hospital	Transplant	Kansas City	KS	Heart	Heart	Adult	Government Rates		107% of Medicare Allowable	N/A		N/A	N/A	107% of Medicare Allowable			100% of Provider's Current Medicare Cost Report for Organ Acquisition	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		39.1232139	-94.818637	679.pdf
University of Kansas Hospital	Transplant	Kansas City	KS	Kidney	Kidney	Adult	Government Rates		107% of Medicare Allowable	N/A		N/A	N/A	107% of Medicare Allowable			100% of Provider's Current Medicare Cost Report for Organ Acquisition	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		39.1232139	-94.818637	680.pdf
University of Kansas Hospital	Transplant	Kansas City	KS	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates		107% of Medicare Allowable	N/A		N/A	N/A	107% of Medicare Allowable			100% of Provider's Current Medicare Cost Report for Organ Acquisition	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		39.1232139	-94.818637	681.pdf
University of Kansas Hospital	Transplant	Kansas City	KS	Liver	Liver	Adult	Government Rates		107% of Medicare Allowable	N/A		N/A	N/A	107% of Medicare Allowable			100% of Provider's Current Medicare Cost Report for Organ Acquisition	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		39.1232139	-94.818637	682.pdf
University of Kansas Hospital	Transplant	Kansas City	KS	Pancreas	Pancreas	Adult	Government Rates		107% of Medicare Allowable	N/A		N/A	N/A	107% of Medicare Allowable			100% of Provider's Current Medicare Cost Report for Organ Acquisition	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		39.1232139	-94.818637	683.pdf
University of Kansas Hospital	Transplant	Kansas City	KS	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Government Rates		107% of Medicare Allowable	N/A		N/A	N/A	107% of Medicare Allowable		100% of Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Admittance for Preparative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		39.1232139	-94.818637	684.pdf
University of Kentucky Medical Center	Transplant	Lexington	KY	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$159,135	35		$2,758 Med/Surg \| $3,183 ICU/CCU	90% of Billed Charges	70% of Billed Charges	Included in Case Rate	55% of Billed Charges			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		38.0285173	-84.6116483	685.pdf
University of Kentucky Medical Center	Transplant	Lexington	KY	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$201,571	35		$2,758 Med/Surg \| $3,183 ICU/CCU	90% of Billed Charges	70% of Billed Charges	55% of Billed Charges	55% of Billed Charges			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		38.0285173	-84.6116483	685.pdf
University of Kentucky Medical Center	Transplant	Lexington	KY	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$101,846	25		$2,758 Med/Surg \| $3,183 ICU/CCU	90% of Billed Charges	70% of Billed Charges	Included in Case Rate				50% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		38.0285173	-84.6116483	685.pdf
University of Kentucky Medical Center	Transplant	Lexington	KY	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$125,186	15		$2,758 Med/Surg \| $3,183 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		38.0285173	-84.6116483	686.pdf
University of Kentucky Medical Center	Transplant	Lexington	KY	Liver	Liver	Adult	Member's Choice		Cadaveric Donor: $203,693 \| Living Donor: $214,302	20		$2,758 Med/Surg \| $3,183 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		38.0285173	-84.6116483	687.pdf
University of Kentucky Medical Center	Transplant	Lexington	KY	Lung	Lung	Adult	Member's Choice		Single: $175,049 \| Bilateral: $196,267	Single: 20 \| Bilateral: 21		$2,758 Med/Surg \| $3,183 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		38.0285173	-84.6116483	688.pdf
University of Kentucky Medical Center	Transplant	Lexington	KY	Pancreas	Pancreas	Adult	Programs of Excellence		$93,259	18		$2,758 Med/Surg \| $3,183 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		38.0285173	-84.6116483	689.pdf
University of Kentucky Medical Center	Transplant	Lexington	KY	Heart	Heart	Adult	Member's Choice		$180,353	18		$2,758 Med/Surg \| $3,183 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	55% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		38.0285173	-84.6116483	690.pdf
University of Kentucky Medical Center	Destination VAD	Lexington	KY	Destination VAD	Destination VAD				Surgical Event: 60% of Billed Charges	N/A		$3,183	90% of Billed Charges	70% of Billed Charges \| VAD Maintenance & Supplies: 55% of Billed Charges				55% of Billed Charges	50% of Billed Charges	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		38.0282464	-84.6119901	690.pdf
University of Kentucky Medical Center	Transplant	Lexington	KY	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor: $100,786 \| Living Donor: $84,872	12		$2,758 Med/Surg \| $3,183 ICU/CCU	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		38.0285173	-84.6116483	691.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$194,250	12		$2,625 Med/Surg; $4,200 ICU/CCU	80% of Billed Charges	70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		38.1889916	-85.8168537	692.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Multi-Organ	Multi-Organ	Adult	Member's Choice		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	100% of Higher Cost Organ, Plus 50% of Lower Cost Organ		$2,625 Med/Surg; $4,200 ICU/CCU	80% of Billed Charges	70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		38.1889916	-85.8168537	693.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Pancreas	Pancreas	Adult	Programs of Excellence		$120,750	10		$2,625 Med/Surg; $4,200 ICU/CCU	80% of Billed Charges	70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		38.1889916	-85.8168537	694.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Liver	Liver	Adult	Member's Choice		Cadaveric Donor: $199,500 \| Living Donor: $210,000	20		$2,625 Med/Surg; $4,200 ICU/CCU	80% of Billed Charges	70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		38.1889916	-85.8168537	695.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	Single Lung: $220,500 \| Bilateral Lung: $231,000	Single Lung: 25 \| Bilateral Lung: 28		$2,625 Med/Surg; $4,200 ICU/CCU	80% of Billed Charges	70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		38.1889916	-85.8168537	696.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$110,250	8		$2,625 Med/Surg; $4,200 ICU/CCU	80% of Billed Charges	70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		38.1889916	-85.8168537	697.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$241,500	30		$2,625 Med/Surg; $4,200 ICU/CCU	80% of Billed Charges	70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		38.1889916	-85.8168537	698.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$189,000	35		$3,150 Med/Surg; $4,200 ICU/CCU	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate				Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Number of Inlier Days plus any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		38.1889916	-85.8168537	699.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$210,000	35		$3,150 Med/Surg; $4,200 ICU/CCU	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate				Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Number of Inlier Days plus any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		38.1889916	-85.8168537	699.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$115,500	25		$3,150 Med/Surg; $4,200 ICU/CCU	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate				Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Number of Inlier Days plus any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		38.1889916	-85.8168537	699.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Member's Choice		$194,250	1st: 25 \| 2nd: 25		$3,150 Med/Surg; $4,200 ICU/CCU	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate				Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Number of Inlier Days plus any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		38.1889916	-85.8168537	699.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Blood/Marrow (Tandem Auto to Related Allo)	Tandem Auto to Allo	Adult	Member's Choice		$325,500	1st: 25 \| 2nd: 35		$3,150 Med/Surg; $4,200 ICU/CCU	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate				Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Number of Inlier Days plus any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		38.1889916	-85.8168537	699.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Blood/Marrow (Tandem Auto to Unrelated Allo)	Tandem Auto to Allo	Adult	Member's Choice		$346,500	1st: 25 \| 2nd: 35		$3,150 Med/Surg; $4,200 ICU/CCU	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate				Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Number of Inlier Days plus any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		38.1889916	-85.8168537	699.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Cord Blood	Cord Blood	Adult	Member's Choice		$252,000	Single: 20 \| Double: 25		$3,150 Med/Surg; $4,200 ICU/CCU	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate				Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when the Number of Inlier Days plus any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		38.1889916	-85.8168537	699.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Heart	Heart	Adult	Government Rates		In State Medicaid Patients: Hospital - 103% of Kentucky Medicaid Professional - 65% of Billed Charges \| In State Medicare Patients: Hospital & Professional - 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: Hospital and Professional - 105% of Kentucky Medicare Allowable	N/A			80% of Billed Charges	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable			100% of Organ Procurement Organization Invoice Cost		N/A	Begins at Evaluation	Begins on the Day of Admission for Transplantation	Ends 365 Days from Discharge		38.1889916	-85.8168537	700.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Liver	Liver	Adult	Government Rates		In State Medicaid Patients: Hospital - 103% of Kentucky Medicaid Professional - 65% of Billed Charges \| In State Medicare Patients: Hospital & Professional - 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: Hospital and Professional - 105% of Kentucky Medicare Allowable	N/A			80% of Billed Charges	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable			100% of Organ Procurement Organization Invoice Cost		N/A	Begins at Evaluation	Begins on the Day of Admission for Transplantation	Ends 365 Days from Discharge		38.1889916	-85.8168537	701.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Lung	Lung	Adult	Government Rates		In State Medicaid Patients: Hospital - 103% of Kentucky Medicaid Professional - 65% of Billed Charges \| In State Medicare Patients: Hospital & Professional - 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: Hospital and Professional - 105% of Kentucky Medicare Allowable	N/A			80% of Billed Charges	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable			100% of Organ Procurement Organization Invoice Cost		N/A	Begins at Evaluation	Begins on the Day of Admission for Transplantation	Ends 365 Days from Discharge		38.1889916	-85.8168537	701.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Heart/Lung	Heart/Lung	Adult	Government Rates		In State Medicaid Patients: Hospital - 103% of Kentucky Medicaid Professional - 65% of Billed Charges \| In State Medicare Patients: Hospital & Professional - 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: Hospital and Professional - 105% of Kentucky Medicare Allowable	N/A			80% of Billed Charges	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable			100% of Organ Procurement Organization Invoice Cost		N/A	Begins at Evaluation	Begins on the Day of Admission for Transplantation	Ends 365 Days from Discharge		38.1889916	-85.8168537	701.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Pancreas	Pancreas	Adult	Government Rates		In State Medicaid Patients: Hospital - 103% of Kentucky Medicaid Professional - 65% of Billed Charges \| In State Medicare Patients: Hospital & Professional - 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: Hospital and Professional - 105% of Kentucky Medicare Allowable	N/A			80% of Billed Charges	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable			100% of Organ Procurement Organization Invoice Cost		N/A	Begins at Evaluation	Begins on the Day of Admission for Transplantation	Ends 365 Days from Discharge		38.1889916	-85.8168537	701.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Kidney	Kidney	Adult	Government Rates		In State Medicaid Patients: Hospital - 103% of Kentucky Medicaid Professional - 65% of Billed Charges \| In State Medicare Patients: Hospital & Professional - 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: Hospital and Professional - 105% of Kentucky Medicare Allowable	N/A			80% of Billed Charges	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable			100% of Organ Procurement Organization Invoice Cost		N/A	Begins at Evaluation	Begins on the Day of Admission for Transplantation	Ends 365 Days from Discharge		38.1889916	-85.8168537	701.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates		In State Medicaid Patients: Hospital - 103% of Kentucky Medicaid Professional - 65% of Billed Charges \| In State Medicare Patients: Hospital & Professional - 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: Hospital and Professional - 105% of Kentucky Medicare Allowable	N/A			80% of Billed Charges	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable			100% of Organ Procurement Organization Invoice Cost		N/A	Begins at Evaluation	Begins on the Day of Admission for Transplantation	Ends 365 Days from Discharge		38.1889916	-85.8168537	701.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates		In State Medicaid Patients: Hospital - 103% of Kentucky Medicaid Professional - 65% of Billed Charges \| In State Medicare Patients: Hospital & Professional - 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: Hospital and Professional - 105% of Kentucky Medicare Allowable	N/A			80% of Billed Charges	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable \| Less Any Applicable Discounts	Included in the Transplant Phase			N/A	Begins at Evaluation	Begins on the Day of Admission for Transplantation	Ends 365 Days from Discharge		38.1889916	-85.8168537	702.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Government Rates		In State Medicaid Patients: Hospital - 103% of Kentucky Medicaid Professional - 65% of Billed Charges \| In State Medicare Patients: Hospital & Professional - 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: Hospital and Professional - 105% of Kentucky Medicare Allowable	N/A			80% of Billed Charges	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable \| Less Any Applicable Discounts	Included in the Transplant Phase			N/A	Begins at Evaluation	Begins on the Day of Admission for Transplantation	Ends 365 Days from Discharge		38.1889916	-85.8168537	702.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates		In State Medicaid Patients: Hospital - 103% of Kentucky Medicaid Professional - 65% of Billed Charges \| In State Medicare Patients: Hospital & Professional - 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: Hospital and Professional - 105% of Kentucky Medicare Allowable	N/A			80% of Billed Charges	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable \| Less Any Applicable Discounts	Included in the Transplant Phase			N/A	Begins at Evaluation	Begins on the Day of Admission for Transplantation	Ends 365 Days from Discharge		38.1889916	-85.8168537	702.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Government Rates		In State Medicaid Patients: Hospital - 103% of Kentucky Medicaid Professional - 65% of Billed Charges \| In State Medicare Patients: Hospital & Professional - 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: Hospital and Professional - 105% of Kentucky Medicare Allowable	N/A			80% of Billed Charges	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable \| Less Any Applicable Discounts	Included in the Transplant Phase			N/A	Begins at Evaluation	Begins on the Day of Admission for Transplantation	Ends 365 Days from Discharge		38.1889916	-85.8168537	702.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Blood/Marrow (Tandem Auto to Related Allo)	Tandem Auto to Allo	Adult	Government Rates		In State Medicaid Patients: Hospital - 103% of Kentucky Medicaid Professional - 65% of Billed Charges \| In State Medicare Patients: Hospital & Professional - 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: Hospital and Professional - 105% of Kentucky Medicare Allowable	N/A			80% of Billed Charges	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable \| Less Any Applicable Discounts	Included in the Transplant Phase			N/A	Begins at Evaluation	Begins on the Day of Admission for Transplantation	Ends 365 Days from Discharge		38.1889916	-85.8168537	702.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Blood/Marrow (Tandem Auto to Unrelated Allo)	Tandem Auto to Allo	Adult	Government Rates		In State Medicaid Patients: Hospital - 103% of Kentucky Medicaid Professional - 65% of Billed Charges \| In State Medicare Patients: Hospital & Professional - 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: Hospital and Professional - 105% of Kentucky Medicare Allowable	N/A			80% of Billed Charges	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable \| Less Any Applicable Discounts	Included in the Transplant Phase			N/A	Begins at Evaluation	Begins on the Day of Admission for Transplantation	Ends 365 Days from Discharge		38.1889916	-85.8168537	702.pdf
University of Louisville Health (Jewish Hospital)	Transplant	Louisville	KY	Cord Blood	Cord Blood	Adult	Government Rates		In State Medicaid Patients: Hospital - 103% of Kentucky Medicaid Professional - 65% of Billed Charges \| In State Medicare Patients: Hospital & Professional - 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: Hospital and Professional - 105% of Kentucky Medicare Allowable	N/A			80% of Billed Charges	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable	In State Medicaid Patients: 103% of Kentucky Medicaid \| In State Medicare Patients: 103% of Kentucky Medicare Allowable \| Out of State Medicaid or Medicare Patients: 105% of Kentucky Medicare Allowable \| Less Any Applicable Discounts	Included in the Transplant Phase			N/A	Begins at Evaluation	Begins on the Day of Admission for Transplantation	Ends 365 Days from Discharge		38.1889916	-85.8168537	702.pdf
University of Louisville Health (Jewish Hospital)	Cellular Immunotherapy	Louisville	KY	Cellular Immunotherapy	Cellular Immunotherapy				Commercial: 60% of Billed Charges \| Government: 107% of Kentucky Medicare Allowable \| Drug Cost: 100% of Wholesale Acquisition Cost	N/A		N/A	N/A	Commercial: 60% of Billed Charges \| Government: 107% of Kentucky Medicare Allowable					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends 365 Days from Discharge		38.1889916	-85.8168537	703.pdf
University of Maryland Medical System	Transplant	Baltimore	MD	Heart	Heart	Adult	Member's Choice		Hospital: 100% of HSCSC Billed Charges \| Professional: 75% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Billed Charges			Reimbursed at 100% of Invoice Charge	Reimbursed at Invoice Charge for the device(s)	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplantation and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	704.pdf
University of Maryland Medical System	Transplant	Baltimore	MD	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric or Living \| Hospital: 100% of HSCSC Billed Charges \| Professional: 75% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Billed Charges			Reimbursed at 100% of Invoice Charge	Reimbursed at Invoice Charge for the device(s)	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplantation and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	705.pdf
University of Maryland Medical System	Transplant	Baltimore	MD	Pancreas	Pancreas	Adult	Programs of Excellence		Hospital: 100% of HSCSC Billed Charges \| Professional: 75% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Billed Charges			Reimbursed at 100% of Invoice Charge	Reimbursed at Invoice Charge for the device(s)	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplantation and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	706.pdf
University of Maryland Medical System	Transplant	Baltimore	MD	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: 100% of HSCSC Billed Charges \| Professional: 75% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Billed Charges	Reimbursed at 100% of HSCRC Billed Charges	Reimbursed at 100% of HSCRC Billed Charges			N/A	Begins at Evaluation	Begins on the day of Admittance for Prepative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	707.pdf
University of Maryland Medical System	Transplant	Baltimore	MD	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: 100% of HSCSC Billed Charges \| Professional: 75% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Billed Charges	Reimbursed at 100% of HSCRC Billed Charges	Reimbursed at 100% of HSCRC Billed Charges			N/A	Begins at Evaluation	Begins on the day of Admittance for Prepative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	707.pdf
University of Maryland Medical System	Transplant	Baltimore	MD	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: 100% of HSCSC Billed Charges \| Professional: 75% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Billed Charges	Reimbursed at 100% of HSCRC Billed Charges	Reimbursed at 100% of HSCRC Billed Charges			N/A	Begins at Evaluation	Begins on the day of Admittance for Prepative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	707.pdf
University of Maryland Medical System	Transplant	Baltimore	MD	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric or Living \| Hospital: 100% of HSCSC Billed Charges \| Professional: 75% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Billed Charges			Reimbursed at 100% of Invoice Charge	Reimbursed at Invoice Charge for the device(s)	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplantation and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	708.pdf
University of Maryland Medical System	Transplant	Baltimore	MD	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	Hospital: 100% of HSCSC Billed Charges \| Professional: 75% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Billed Charges			Reimbursed at 100% of Invoice Charge	Reimbursed at Invoice Charge for the device(s)	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplantation and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	709.pdf
University of Maryland Medical System	Transplant	Baltimore	MD	Lung	Lung	Adult	Member's Choice		Hospital: 100% of HSCSC Billed Charges \| Professional: 75% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of HSCRC Billed Charges			Reimbursed at 100% of Invoice Charge	Reimbursed at Invoice Charge for the device(s)	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplantation and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	710.pdf
University of Maryland Medical System	Cellular Immunotherapy	Baltimore	MD	Cellular Immunotherapy	Cellular Immunotherapy				Hospital: 100% of the State of Maryland HSCRC rates \| Professional: 75% of Billed Charges \| Drug Cost: 100% of HSCRC rates	N/A		N/A	N/A	Hospital: 100% of HSCRC Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins One (1) Day Prior to Transplantation and Ends at Discharge	Ends One (1) Year from Discharge		39.2846853	-76.6907077	711.pdf
University of Maryland Medical System	Transplant	Baltimore	MD	Heart	Heart	Adult	Government Rates		Hospital: 100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discounts \| Professional: 75% of Billed Charges	N/A		N/A		Hospital: 100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discounts \| Professional: 75% of Billed Charges			100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discount		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	712.pdf
University of Maryland Medical System	Transplant	Baltimore	MD	Kidney	Kidney	Adult	Government Rates		Hospital: 100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discounts \| Professional: 75% of Billed Charges	N/A		N/A		Hospital: 100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discounts \| Professional: 75% of Billed Charges			100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discount		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	713.pdf
University of Maryland Medical System	Transplant	Baltimore	MD	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates		Hospital: 100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discounts \| Professional: 75% of Billed Charges	N/A		N/A		Hospital: 100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discounts \| Professional: 75% of Billed Charges			100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discount		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	714.pdf
University of Maryland Medical System	Transplant	Baltimore	MD	Liver	Liver	Adult	Government Rates		Hospital: 100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discounts \| Professional: 75% of Billed Charges	N/A		N/A		Hospital: 100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discounts \| Professional: 75% of Billed Charges			100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discount		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	715.pdf
University of Maryland Medical System	Transplant	Baltimore	MD	Lung	Lung	Adult	Government Rates		Hospital: 100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discounts \| Professional: 75% of Billed Charges	N/A		N/A		Hospital: 100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discounts \| Professional: 75% of Billed Charges			100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discount		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	716.pdf
University of Maryland Medical System	Transplant	Baltimore	MD	Pancreas	Pancreas	Adult	Government Rates		Hospital: 100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discounts \| Professional: 75% of Billed Charges	N/A		N/A		Hospital: 100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discounts \| Professional: 75% of Billed Charges			100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discount		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	717.pdf
University of Maryland Medical System	Transplant	Baltimore	MD	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates		Hospital: 100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discounts \| Professional: 75% of Billed Charges	N/A		N/A		Hospital: 100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discounts \| Professional: 75% of Billed Charges	100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discount	100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discount			N/A	Begins at Evaluation	Begins on Day of Admission for Preparative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	718.pdf
University of Maryland Medical System	Transplant	Baltimore	MD	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates		Hospital: 100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discounts \| Professional: 75% of Billed Charges	N/A		N/A		Hospital: 100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discounts \| Professional: 75% of Billed Charges	100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discount	100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discount			N/A	Begins at Evaluation	Begins on Day of Admission for Preparative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	718.pdf
University of Maryland Medical System	Transplant	Baltimore	MD	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Related	Adult	Government Rates		Hospital: 100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discounts \| Professional: 75% of Billed Charges	N/A		N/A		Hospital: 100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discounts \| Professional: 75% of Billed Charges	100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discount	100% of Billed Charges, Minus the then Current HSCRC Medicare Advantage or Managed Medicaid Discount			N/A	Begins at Evaluation	Begins on Day of Admission for Preparative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		39.2848183	-76.6905365	718.pdf
University of Miami Hospital & Clinics	Transplant	Miami	FL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $191,589 \| Professional: 70% of Billed Charges	50		$4,338	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Admittance for Preparative Therapy and Ends when the Number of Inlier Days have Expired	Ends One (1) Year from Discharge		25.7825453	-80.2994984	719.pdf
University of Miami Hospital & Clinics	Transplant	Miami	FL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $239,639 \| Professional: 70% of Billed Charges	45		$4,338	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Admittance for Preparative Therapy and Ends when the Number of Inlier Days have Expired	Ends One (1) Year from Discharge		25.7825453	-80.2994984	719.pdf
University of Miami Hospital & Clinics	Transplant	Miami	FL	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $102,957 \| Professional: 70% of Billed Charges	30		$4,338	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Admittance for Preparative Therapy and Ends when the Number of Inlier Days have Expired	Ends One (1) Year from Discharge		25.7825453	-80.2994984	719.pdf
University of Miami Hospital & Clinics	Transplant	Miami	FL	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $173,056 \| Professional: 70% of Billed Charges	30 Days (Each Transplant)		$4,338	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Admittance for Preparative Therapy and Ends when the Number of Inlier Days have Expired	Ends One (1) Year from Discharge		25.7825453	-80.2994984	719.pdf
University of Miami Hospital & Clinics	Transplant	Miami	FL	Blood/Marrow (Tandem Auto to Related Allo)	Tandem Auto to Allo	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $269,318 \| Professional: 70% of Billed Charges	45 Days (Each Transplant)		$4,338	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Admittance for Preparative Therapy and Ends when the Number of Inlier Days have Expired	Ends One (1) Year from Discharge		25.7825453	-80.2994984	719.pdf
University of Miami Hospital & Clinics	Transplant	Miami	FL	Blood/Marrow (Tandem Auto to Unrelated Allo)	Tandem Auto to Allo	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $323,398 \| Professional: 70% of Billed Charges	50 Days (Each Transplant)		$4,338	80% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Admittance for Preparative Therapy and Ends when the Number of Inlier Days have Expired	Ends One (1) Year from Discharge		25.7825453	-80.2994984	719.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	$167,000	30		Days 31 - 40: $3,200 per Day \| Days 40 - Discharge: 85% of Billed Charges	N/A	85% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period \| If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Paid at Invoice Cost			N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		42.2733786	-83.7727088	720.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	$193,600	34		Days 35 - 44: $3,200 per Day \|Days 45 - Discharge: 85% of Billed Charges	N/A	85% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period \| If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Paid at Invoice Cost			N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		42.2733786	-83.7727088	720.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	$103,700	26		Days 27 - 36: $3,200 per Day \|Days 37 - Discharge: 85% of Billed Charges	N/A	85% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period \| If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Paid at Invoice Cost			N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		42.2733786	-83.7727088	720.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceSELECT	$86,400	26		Days 27 - 36: $3,200 per Day \| Days 37 - Discharge: $85% of Billed Charges	N/A	85% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period \| If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Paid at Invoice Cost			N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends One (1) Year from Discharge		42.2733786	-83.7727088	720.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Blood/Marrow (Tandem Auto to Related Allo)	Tandem Auto to Allo	Adult	Programs of Excellence	PerformanceSELECT	$101,800	23		Days 24 - 33: $3,200 per Day \| Days 34 - Discharge: $85% of Billed Charges	N/A	85% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period \| If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Paid at Invoice Cost			N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends One (1) Year from Discharge		42.2733786	-83.7727088	720.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$175,500	34		Days 35 - 44: $3,200 per Day \| Days 45 - Discharge: $85% of Billed Charges	N/A	85% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period \| If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Paid at Invoice Cost			N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		42.2733786	-83.7727088	721.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$215,200	37		Days 38 - 47: $3,200 per Day \| Days 48 - Discharge: $85% of Billed Charges	N/A	85% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period \| If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Paid at Invoice Cost			N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		42.2733786	-83.7727088	721.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$139,900	32		Days 33 - 42: $3,200 per Day \| Days 43 - Discharge: $85% of Billed Charges	N/A	85% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period \| If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Paid at Invoice Cost			N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		42.2733786	-83.7727088	721.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Pediatric	Programs of Excellence		$112,200	32		Days 33 - 42: $3,200 per Day \| Days 43 - Discharge: $85% of Billed Charges	N/A	85% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period \| If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Paid at Invoice Cost			N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends One (1) Year from Discharge		42.2733786	-83.7727088	721.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Blood/Marrow (Tandem Auto to Related Allo)	Tandem Auto to Allo	Pediatric	Programs of Excellence		$122,200	33		Days 34 - 43: $3,200 per Day \| Days 44 - Discharge: $85% of Billed Charges	N/A	85% of Billed Charges	Charges Included in the Transplant Case Rate if Provided During the Inlier Days Period \| If Harvesting is Provided Prior to Inlier Period, Reimbursement Shall be at the Pre-Transplant Rate	Paid at Invoice Cost			N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends One (1) Year from Discharge		42.2733786	-83.7727088	721.pdf
University of Michigan Medical Center	Cancer	Ann Arbor	MI	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															42.273315	-83.7727946	722.pdf
University of Michigan Medical Center	Cellular Immunotherapy	Ann Arbor	MI	Cellular Immunotherapy	Cellular Immunotherapy				60% of Billed Charges \| Drug Cost: 105% of Invoice Cost	N/A		N/A	N/A	70% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends 365 Days from Discharge		42.273315	-83.7727946	723.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Heart	Heart	Pediatric	Programs of Excellence		$194,000	40		Days 41 - 50: $3,200 per Day \| Days 51 - Discharge: $85% of Billed Charges	N/A	85% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		42.2733786	-83.7727088	724.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Heart	Heart	Adult	Member's Choice		$166,300	28		Days 29 - 38: $3,200 per Day \| Days 39 - Discharge: 85% of Billed Charges	N/A	85% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		42.2733786	-83.7727088	725.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Kidney	Kidney	Pediatric	Programs of Excellence		$83,200	11		Days 12 - 21: $3,200 per Day \| Days 22 - Discharge: $85% of Billed Charges	N/A	85% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		42.2733786	-83.7727088	726.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$73,900	7		Days 8 - 17: $3,200 per Day \| Days 18 - Discharge: 85% of Billed Charges	N/A	85% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		42.2733786	-83.7727088	727.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$114,700	11		Days 12 - 21: $3,200 per Day \| Days 22 - Discharge: 85% of Billed Charges	N/A	85% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		42.2733786	-83.7727088	728.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Liver	Liver	Pediatric	Programs of Excellence		$176,600	17		Days 18 - 27: $3,200 per Day \| Days 28 - Discharge: $85% of Billed Charges	N/A	85% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		42.2733786	-83.7727088	729.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	$179,100	20		Days 21 - 30: $3,200 per Day \| Days 31 - Discharge: 85% of Billed Charges	N/A	85% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		42.2733786	-83.7727088	730.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Lung	Lung	Adult	Member's Choice		Single $150,000 \| Bilateral $157,600	16 20		Single Lung: Days 17 - 26: $3,200 per Day \| Days 27 - Discharge: 85% of Billed Charges \| Bilateral Lung: Days 21 - 30: $3,20000 per Day \| Days 31 - Discharge: 85% of Billed Charges	N/A	85% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		42.2733786	-83.7727088	731.pdf
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Pancreas	Pancreas	Adult	Programs of Excellence		$97,500	12		Days 13 - 22: $3,200 per Day \| Days 23 - Discharge: 85% of Billed Charges	N/A	85% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins 7 Days Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired or Discharge, Whichever is Earlier	Ends 365 Days from Discharge		42.2733786	-83.7727088	732.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Heart/Kidney	Heart/Kidney	Adult	Member's Choice		$190,000	25		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 65% of Billed Charges	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	733.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Heart/Lung	Heart/Lung	Adult	Member's Choice		$150,000	35		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 65% of Billed Charges	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	734.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Intestine	Intestine	Adult	Member's Choice		Cadaveric Donor: $200,000 \| Living Donor: $175,000	35		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 65% of Billed Charges	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	735.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Intestine/Liver	Intestine/Liver	Adult	Member's Choice		$275,000	40		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 65% of Billed Charges	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	736.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Islet (Allogeneic)	Islet	Adult	Member's Choice		$95,000	15		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate	N/A	N/A	60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	737.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Islet (Autologous)	Islet	Adult	Member's Choice		$125,000	15		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate	N/A	N/A	60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	737.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Islet (Allogeneic)	Islet	Pediatric	Member's Choice		$95,000	15		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	737.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Islet (Autologous)	Islet	Pediatric	Member's Choice		$125,000	15		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	737.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		$190,000	25		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 65% of Billed Charges	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	738.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Kidney/Lung	Kidney/Lung	Adult	Member's Choice		$190,000	25		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 65% of Billed Charges	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	739.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor: $140,000 \| Living Donor: $200,000	25 \| 20		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 65% of Billed Charges	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	740.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$175,000	50		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	741.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$225,000	50		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	741.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$95,000	20		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	741.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Blood/Marrow (Cord Blood)	Cord Blood	Pediatric	Programs of Excellence		$200,000	50		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges		Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	741.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Kidney	Kidney	Pediatric	Programs of Excellence		Cadaveric Donor: $120,000 \| Living Donor: $110,000	15		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 65% of Billed Charges	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	742.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor: $85,000 \| Living Donor: $75,000	12		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 65% of Billed Charges	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	742.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	$140,000	50		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	743.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	$165,000	50		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	743.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Programs of Excellence	PerformanceSELECT	$185,000	50		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	743.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	$90,000	20		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	743.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	Without Prior VAD Placement: $125,000 \| With Prior VAD Placement: $150, 000	25		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 65% of Billed Charges	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	744.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	$110,000	20		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 65% of Billed Charges	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	745.pdf
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor Meld Score 20: $180,000 \| Living Donor: $140,000	20 \| 25 \| 25		$3,200 Med/Surg \| $3,200 ICU/CCU	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at 65% of Billed Charges	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		44.970797	-93.3315181	746.pdf
University of Minnesota Medical Center, Fairview	Cellular Immunotherapy	Minneapolis	MN	Cellular Immunotherapy	Cellular Immunotherapy				60% of Billed Charges \| Drug Cost: 100% of Wholesale Acquisition Cost (WAC)	N/A		N/A	N/A	60% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends One (1) Year from Discharge		44.9706755	-93.3316894	747.pdf
University of Mississippi Medical Center	Transplant	Jackson	MS	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		Allogeneic Related: $230,000 \| Haploid: $250,000	Allogeneic Related: 30 \| Haploid: 35		$3,500 Med/Surg \| $5,000 ICU/CCU	100% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from the End of the Transplant Phase		32.3104541	-90.2638272	748.pdf
University of Mississippi Medical Center	Transplant	Jackson	MS	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		Allogeneic Unrelated: $255,000 \| Haploid: $250,000	Allogeneic Unrelated: 35 \| Haploid: 35		$3,500 Med/Surg \| $5,000 ICU/CCU	100% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from the End of the Transplant Phase		32.3104541	-90.2638272	748.pdf
University of Mississippi Medical Center	Transplant	Jackson	MS	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$145,000	25		$3,500 Med/Surg \| $5,000 ICU/CCU	100% of Billed Charges	70% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			N/A	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from the End of the Transplant Phase		32.3104541	-90.2638272	748.pdf
University of Mississippi Medical Center	Transplant	Jackson	MS	Heart	Heart	Adult	Member's Choice		$280,000	26		$3,500 Med/Surg \| $5,000 ICU/CCU	100% of Billed Charges	70% of Billed Charges			Included in Case Rate	Invoice Cost + 15%	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) from Discharge		32.3104541	-90.2638272	749.pdf
University of Mississippi Medical Center	Transplant	Jackson	MS	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$115,000	8		$3,500 Med/Surg \| $5,000 ICU/CCU	100% of Billed Charges	70% of Billed Charges			Included in Case Rate	Invoice Cost + 15%	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) from Discharge		32.3104541	-90.2638272	750.pdf
University of Mississippi Medical Center	Transplant	Jackson	MS	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceELITE	$195,000	12		$3,500 Med/Surg \| $5,000 ICU/CCU	100% of Billed Charges	70% of Billed Charges			Included in Case Rate	Invoice Cost + 15%	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) from Discharge		32.3104541	-90.2638272	751.pdf
University of Mississippi Medical Center	Transplant	Jackson	MS	Pancreas	Pancreas	Adult	Programs of Excellence		$145,000	10		$3,500 Med/Surg \| $5,000 ICU/CCU	100% of Billed Charges	70% of Billed Charges			Included in Case Rate	Invoice Cost + 15%	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) from Discharge		32.3104541	-90.2638272	752.pdf
University of Mississippi Medical Center	Transplant	Jackson	MS	Liver	Liver	Adult	Member's Choice		$235,000	15		$3,500 Med/Surg \| $5,000 ICU/CCU	100% of Billed Charges	70% of Billed Charges			Included in Case Rate	Invoice Cost + 15%	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) from Discharge		32.3104541	-90.2638272	753.pdf
University of Mississippi Medical Center	Transplant	Jackson	MS	Multi-Organ	Multi-Organ	Adult	Programs of Excellence	PerformanceQUALITY	100% of Highest Organ rate plus 50% of Lower Organ Rate	Equal to number of days of more expensive organ		$3,500 Med/Surg \| $5,000 ICU/CCU	100% of Billed Charges	70% of Billed Charges			Included in Case Rate	Invoice Cost + 15%	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) from Discharge		32.3104541	-90.2638272	754.pdf
University of Mississippi Medical Center	Cellular Immunotherapy	Jackson	MS	Cellular Immunotherapy	Cellular Immunotherapy																			32.3104541	-90.2638272	866.pdf
University of New Mexico Health Sciences Center	Transplant	Albuquerque	NM	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$120,000	12		$2,750 Med/Surg \| $4,000 ICU/CCU	90% of Billed Charges	Inpatient: Lesser of 90% of Billed Charges or $2,750 Med/Surg; $4,000 ICU/CCU \| Outpatient: 70% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends Ninety (90) Days from Discharge		35.0823897	-106.7466905	755.pdf
University of New Mexico Health Sciences Center (Medicare Advantage or Medicaid)	Transplant	Albuquerque	NM	Kidney	Kidney	Adult	Government Rates		$120,000	12		$2,173 Med/Surg \| $3,200 ICU/CCU	75% of Billed Charges	Inpatient: Lesser of 75% of Billed Charges or $2,173 Med/Surg; $3,200 ICU/CCU \| Outpatient: 60% of Billed Charges			Included in Case Rate	N/A	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends Ninety (90) Days from Discharge		35.0823897	-106.7466905	756.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$190,836	N/A		N/A	100% of Billed Charges	65% of Billed Charges	Included in Case Rate	65% of Billed Charges			If Billed Charges Exceed $381,675, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	757.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$190,836	N/A		N/A	100% of Billed Charges	65% of Billed Charges	Included in Case Rate	65% of Billed Charges			If Billed Charges Exceed $381,675, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	757.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$235,186	N/A		N/A	100% of Billed Charges	65% of Billed Charges	Included in Case Rate	65% of Billed Charges			If Billed Charges Exceed $470,371 Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	757.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$235,186	N/A		N/A	100% of Billed Charges	65% of Billed Charges	Included in Case Rate	65% of Billed Charges			If Billed Charges Exceed $470,371 Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	757.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$127,672	N/A		N/A	100% of Billed Charges	65% of Billed Charges	Included in Case Rate	N/A			If Billed Charges Exceed $255,344, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	757.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$127,672	N/A		N/A	100% of Billed Charges	65% of Billed Charges	Included in Case Rate	N/A			If Billed Charges Exceed $255,344, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	757.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Blood/Marrow (Cord Blood)	Cord Blood	Pediatric	Programs of Excellence		Single: $235,186 \| Double: $298,350	N/A		N/A	100% of Billed Charges	65% of Billed Charges	Included in the Case Rate	65% of Billed Charges			If Billed Charges Exceed $470,371 for Single and $596,699 for Double, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	757.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Programs of Excellence	PerformanceQUALITY	Single: $235,186 \| Double: $298,350	N/A		N/A	100% of Billed Charges	65% of Billed Charges	Included in the Case Rate	65% of Billed Charges			If Billed Charges Exceed $470,371 for Single and $596,699 for Double, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	757.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Tandem (Auto-to-Auto)	Tandem Auto to Auto	Pediatric	Programs of Excellence		1st Transplant: $127,672 \| Each Additional Transplant: $108,522	N/A		N/A	100% of Billed Charges	65% of Billed Charges	Included in the Case Rate	65% of Billed Charges			If Billed Charges Exceed $255,344 for the 1st Transplant and $217,045 for Each Additional Transplant, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	757.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Tandem (Auto-to-Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceQUALITY	1st Transplant: $127,672 \| Each Additional Transplant: $108,522	N/A		N/A	100% of Billed Charges	65% of Billed Charges	Included in the Case Rate	65% of Billed Charges			If Billed Charges Exceed $255,344 for the 1st Transplant and $217,045 for Each Additional Transplant, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	757.pdf
University of North Carolina Hospitals	Transplant	Charlotte	NC	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates		102% of Applicable Medicare DRG	N/A	N/A	N/A	N/A	102% of Medicare Allowable \| If Medicare Fee Schedule, MS-DRG, or APC Code are Unavailable: 54% of Billed Charges	102% of Hospital Acquisition Cost, Per D-4 Worksheet	102% of Medicare Allowable			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		35.2030724	-80.9802543	758.pdf
University of North Carolina Hospitals	Transplant	Charlotte	NC	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Government Rates		102% of Applicable Medicare DRG	N/A	N/A	N/A	N/A	102% of Medicare Allowable \| If Medicare Fee Schedule, MS-DRG, or APC Code are Unavailable: 54% of Billed Charges	102% of Hospital Acquisition Cost, Per D-4 Worksheet	102% of Medicare Allowable			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		35.2030724	-80.9802543	758.pdf
University of North Carolina Hospitals	Transplant	Charlotte	NC	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates		102% of Applicable Medicare DRG	N/A	N/A	N/A	N/A	102% of Medicare Allowable \| If Medicare Fee Schedule, MS-DRG, or APC Code are Unavailable: 54% of Billed Charges	102% of Hospital Acquisition Cost, Per D-4 Worksheet	102% of Medicare Allowable			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		35.2030724	-80.9802543	758.pdf
University of North Carolina Hospitals	Transplant	Charlotte	NC	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Government Rates		102% of Applicable Medicare DRG	N/A	N/A	N/A	N/A	102% of Medicare Allowable \| If Medicare Fee Schedule, MS-DRG, or APC Code are Unavailable: 54% of Billed Charges	102% of Hospital Acquisition Cost, Per D-4 Worksheet	102% of Medicare Allowable			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		35.2030724	-80.9802543	758.pdf
University of North Carolina Hospitals	Transplant	Charlotte	NC	Blood/Marrow (Double Cord Blood)	Cord Blood	Adult	Government Rates		102% of Applicable Medicare DRG	N/A	N/A	N/A	N/A	102% of Medicare Allowable \| If Medicare Fee Schedule, MS-DRG, or APC Code are Unavailable: 54% of Billed Charges	102% of Hospital Acquisition Cost, Per D-4 Worksheet	102% of Medicare Allowable			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		35.2030724	-80.9802543	758.pdf
University of North Carolina Hospitals	Transplant	Charlotte	NC	Tandem (Auto-to-Auto)	Tandem Auto to Auto	Adult	Government Rates		102% of Applicable Medicare DRG	N/A	N/A	N/A	N/A	102% of Medicare Allowable \| If Medicare Fee Schedule, MS-DRG, or APC Code are Unavailable: 54% of Billed Charges	102% of Hospital Acquisition Cost, Per D-4 Worksheet	102% of Medicare Allowable			N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		35.2030724	-80.9802543	758.pdf
University of North Carolina Hospitals	Destination VAD	Chapel Hill	NC	Destination VAD	Destination VAD				Surgical Event: 75% of Billed Charges	N/A		Hospital: 75% of Billed Charges \| Professional: 65% of Billed Charges	N/A	65% of Billed Charges				75% of Billed Charges	N/A	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Ends 365 Days from Discharge		35.9209539	-79.0743961	759.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Heart	Heart	Adult	Member's Choice		$201,586	N/A		N/A	100% of Billed Charges	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed $403,175, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	759.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Heart	Heart	Pediatric	Member's Choice		$201,586	N/A		N/A	100% of Billed Charges	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed $403,175, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	759.pdf
University of North Carolina Hospitals	Transplant	Charlotte	NC	Kidney	Kidney	Adult	Government Rates		102% of Applicable Medicare DRG	N/A		N/A	N/A	102% of Medicare Allowable \| If Medicare Fee Schedule, MS-DRG, or APC Code are Unavailable: 54% of Billed Charges			102% of Organ Acquisition Cost, Pursuant to most Recent D-4 Worksheet	102% of Medicare Allowable Amount	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		35.2030724	-80.9802543	759.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$108,858	N/A		N/A	100% of Billed Charges	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed $217,713, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	760.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Kidney	Kidney	Pediatric	Member's Choice		$108,858	N/A		N/A	100% of Billed Charges	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed $217,713, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	760.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		65% of Billed Charges	N/A		N/A	N/A	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	761.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Kidney/Pancreas	Kidney/Pancreas	Pediatric	Member's Choice		65% of Billed Charges	N/A		N/A	N/A	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	761.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Liver	Liver	Pediatric	Member's Choice		65% of Billed Charges	N/A		65% of Billed Charges	N/A	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	762.pdf
University of North Carolina Hospitals	Transplant	Charlotte	NC	Liver	Liver	Adult	Government Rates		102% of Applicable Medicare DRG	N/A		N/A	N/A	102% of Medicare Allowable \| If Medicare Fee Schedule, MS-DRG, or APC Code are Unavailable: 54% of Billed Charges			102% of Organ Acquisition Cost, Pursuant to most Recent D-4 Worksheet	102% of Medicare Allowable Amount	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		35.2030724	-80.9802543	763.pdf
University of North Carolina Hospitals	Transplant	Charlotte	NC	Liver	Liver	Pediatric	Government Rates		102% of Applicable Medicare DRG	N/A		N/A	N/A	102% of Medicare Allowable \| If Medicare Fee Schedule, MS-DRG, or APC Code are Unavailable: 54% of Billed Charges			102% of Organ Acquisition Cost, Pursuant to most Recent D-4 Worksheet	102% of Medicare Allowable Amount	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		35.2030724	-80.9802543	763.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Lung	Lung	Adult	Member's Choice		$188,147	N/A		N/A	100% of Billed Charges	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed $376,296, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	764.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Lung	Lung	Pediatric	Member's Choice		$188,147	N/A		N/A	100% of Billed Charges	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed $376,296, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	764.pdf
University of North Carolina Hospitals	Transplant	Charlotte	NC	Lung	Lung	Adult	Government Rates		102% of Applicable Medicare DRG	N/A		N/A	N/A	102% of Medicare Allowable \| If Medicare Fee Schedule, MS-DRG, or APC Code are Unavailable: 54% of Billed Charges			102% of Organ Acquisition Cost, Pursuant to most Recent D-4 Worksheet	102% of Medicare Allowable Amount	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		35.2030724	-80.9802543	765.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Pancreas	Pancreas	Adult	Programs of Excellence		65% of Billed Charges	N/A			100% of Billed Charges	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	766.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Pancreas	Pancreas	Pediatric	Programs of Excellence		65% of Billed Charges	N/A		N/A	N/A	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	766.pdf
University of North Carolina Hospitals	Transplant	Charlotte	NC	Pancreas	Pancreas	Adult	Government Rates		102% of Applicable Medicare DRG	N/A		N/A	N/A	102% of Medicare Allowable \| If Medicare Fee Schedule, MS-DRG, or APC Code are Unavailable: 54% of Billed Charges			102% of Organ Acquisition Cost, Pursuant to most Recent D-4 Worksheet	102% of Medicare Allowable Amount	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		35.2030724	-80.9802543	767.pdf
University of North Carolina Hospitals	Transplant	Charlotte	NC	Heart/VAD	Heart	Adult	Government Rates		102% of Applicable Medicare DRG	N/A		N/A	N/A	102% of Medicare Allowable \| If Medicare Fee Schedule, MS-DRG, or APC Code are Unavailable: 54% of Billed Charges			102% of Organ Acquisition Cost, Pursuant to most Recent D-4 Worksheet	102% of Medicare Allowable Amount	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		35.2030724	-80.9802543	768.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Multi-Organ	Multi-Organ	Adult	Member's Choice		65% of Billed Charges	N/A		N/A		65% of Billed Charges	Included in the Case Rate	65% of Billed Charges				Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	769.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Multi-Organ	Multi-Organ	Pediatric	Member's Choice		65% of Billed Charges	N/A		N/A		65% of Billed Charges	Included in the Case Rate	65% of Billed Charges				Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	769.pdf
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	$188,147	N/A		N/A	100% of Billed Charges	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed $376,296, Payment will be the Transplant Case Rate, Plus 65% of the Excess Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends 365 Days from Discharge		35.9210234	-79.0743104	770.pdf
University of Utah Medical Center	Transplant	Salt Lake City	UT	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	Single or Bilateral: $152,279	24		$2,679	90% of Billed Charges	80% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	For Outlier Days only, Never Less than 45% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.7765867	-111.990696	771.pdf
University of Utah Medical Center	Transplant	Salt Lake City	UT	Pancreas	Pancreas	Adult	Programs of Excellence		$84,340	16		$2,679	90% of Billed Charges	80% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	For Outlier Days only, Never Less than 45% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.7765867	-111.990696	772.pdf
University of Utah Medical Center	Transplant	Salt Lake City	UT	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$130,352	40		$2,653	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			For Outlier Days only, Never Less than 45% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.7765867	-111.990696	773.pdf
University of Utah Medical Center	Transplant	Salt Lake City	UT	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$180,299	40		$2,679	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	N/A			For Outlier Days only, Never Less than 45% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.7765867	-111.990696	773.pdf
University of Utah Medical Center	Transplant	Salt Lake City	UT	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$201,010	40		$2,653	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			For Outlier Days only, Never Less than 45% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.7765867	-111.990696	773.pdf
University of Utah Medical Center	Transplant	Salt Lake City	UT	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$127,914	25		$2,679	90% of Billed Charges	80% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	For Outlier Days only, Never Less than 45% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.7765867	-111.990696	774.pdf
University of Utah Medical Center	Destination VAD	Salt Lake City	UT	Destination VAD	Destination VAD				Surgical Event: 72% of Billed Charges	N/A		Inpatient Per Diem: $2,537	Inpatient Services: Lesser of 90% of Billed Charges or $2,386	Outpatient Care: 80% of Billed Charges				100% of Invoice Cost	Inpatient Services: Lesser of 90% of Billed Charges or $2,288, but never less than 45% of Billed Charges	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		40.7765867	-111.990696	774.pdf
University of Utah Medical Center	Transplant	Salt Lake City	UT	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$111,751	16		$2,679	90% of Billed Charges	80% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	For Outlier Days only, Never Less than 45% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.7765867	-111.990696	775.pdf
University of Utah Medical Center	Transplant	Salt Lake City	UT	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor: $54,821 \| Living Donor: $76,140	16		$2,679	90% of Billed Charges	80% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	For Outlier Days only, Never Less than 45% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.7765867	-111.990696	776.pdf
University of Utah Medical Center	Transplant	Salt Lake City	UT	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor: $152,279	20		$2,679	90% of Billed Charges	80% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	For Outlier Days only, Never Less than 45% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.7765867	-111.990696	777.pdf
University of Utah Medical Center	Transplant	Salt Lake City	UT	Multi-Organ	Multi-Organ	Adult	Member's Choice		100% of Higher Cost Organ, Plus 50% of Lower Cost Organ	Equal to Higher Priced Organ		$2,679	90% of Billed Charges	80% of Billed Charges			Reimbursed at Invoice Cost	Reimbursed at Invoice Cost	For Outlier Days only, Never Less than 45% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		40.7765867	-111.990696	778.pdf
University of Utah Medical Center	Cellular Immunotherapy	Salt Lake City	UT	Cellular Immunotherapy	Cellular Immunotherapy				80% of Billed Charges \| Drug Cost: 100% of Wholesale Acquisition Cost (WAC)	N/A		N/A	N/A	80% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends 365 Days from Discharge		40.7765867	-111.990696	779.pdf
University of Utah Medical Center	Cancer	Salt Lake City	UT	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															40.7765867	-111.990696	780.pdf
University of Washington Medical Center	Transplant	Seattle	WA	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		Hospital: $165,000 \| Professional: 77% of Billed Charges	N/A		N/A	80% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 77% of Billed Charges			Included in Case Rate	N/A	Hospital: $280,000 & 79% of Billed Charges Thereafter	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	781.pdf
University of Washington Medical Center	Transplant	Seattle	WA	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $190,000 \| Professional: 77% of Billed Charges	N/A		N/A	80% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 77% of Billed Charges			Included in Case Rate	During Transplant Phase: Charges Included in Case Rate\| Outside Transplant Phase: Charges Reimbursed at: Hospital 75% of Billed Charges Professional: 77% of Billed Charges	Hospital: $340,000 & 79% of Billed Charges Thereafter	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	782.pdf
University of Washington Medical Center	Destination VAD	Seattle	WA	Destination VAD	Destination VAD				Surgical Event: 75% of Billed Charges	N/A		N/A	N/A	Hospital: 75% of Billed Charges \| Professional: 77% of Billed Charges				75% of Billed Charges	N/A	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		47.613007	-122.4122753	782.pdf
University of Washington Medical Center	Transplant	Seattle	WA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	Hospital: $105,000 \| Professional: 77% of Billed Charges	N/A		N/A	80% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 77% of Billed Charges			Included in Case Rate	N/A	Hospital: $170,000 & 79% of Billed Charges Thereafter	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	783.pdf
University of Washington Medical Center	Transplant	Seattle	WA	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	Hospital: $175,000 \| Professional: 77% of Billed Charges	N/A		N/A	80% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 77% of Billed Charges			Included in Case Rate	N/A	Hospital: $270,000 & 79% of Billed Charges Thereafter	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	784.pdf
University of Washington Medical Center	Transplant	Seattle	WA	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	Single Lung Hospital: $185,000 \| Single Lung Professional: 77% of Billed Charges \| Bilateral Lung Hospital: $190,000 \| Bilateral Lung Professional: 77% of Billed Charges	N/A		N/A	80% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 77% of Billed Charges			Included in Case Rate	N/A	Single Lung \| Hospital: $290,000 & 79% of Billed Charges Thereafter \| Bilateral Lung \| $300,000 & 79% of Billed Charges Thereafter	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	785.pdf
University of Washington Medical Center	Transplant	Seattle	WA	Pancreas	Pancreas	Adult	Programs of Excellence		Hospital: $140,000 \| Professional: 77% of Billed Charges	N/A		N/A	80% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 77% of Billed Charges			Included in Case Rate	N/A	Hospital: $180,000 & 79% of Billed Charges Thereafter	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	786.pdf
University of Washington Medical Center	Transplant	Seattle	WA	Multi-Organ	Multi-Visceral	Adult	Member's Choice		Hospital: 75% of Billed Charges \| Professional: 77% of Billed Charges	N/A		N/A	80% of Billed Charges	Hospital: 75% of Billed Charges \| Professional: 77% of Billed Charges			Included in Case Rate		N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	787.pdf
University of Washington Medical Center (Applies to WA or OR Medicaid Only)	Transplant	Seattle	WA	Heart	Heart	Adult	Government Rates		Hospital: 200% ofCMS \| Professional: 77% of Billed Charges	N/A		N/A	N/A	Hospital: 200% of CMS \| Professional: 77% of Billed Charges			100% Organ Procurement Organization rate	75% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	788.pdf
University of Washington Medical Center (Applies to WA or OR Medicaid Only)	Transplant	Seattle	WA	Kidney	Kidney	Adult	Government Rates		Hospital: 200% ofCMS \| Professional: 77% of Billed Charges	N/A		N/A	N/A	Hospital: 200% of CMS \| Professional: 77% of Billed Charges			100% Organ Procurement Organization rate	75% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	788.pdf
University of Washington Medical Center (Applies to WA or OR Medicaid Only)	Transplant	Seattle	WA	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates		Hospital: 200% ofCMS \| Professional: 77% of Billed Charges	N/A		N/A	N/A	Hospital: 200% of CMS \| Professional: 77% of Billed Charges			100% Organ Procurement Organization rate	75% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	788.pdf
University of Washington Medical Center (Applies to WA or OR Medicaid Only)	Transplant	Seattle	WA	Liver	Liver	Adult	Government Rates		Hospital: 200% ofCMS \| Professional: 77% of Billed Charges	N/A		N/A	N/A	Hospital: 200% of CMS \| Professional: 77% of Billed Charges			100% Organ Procurement Organization rate	75% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	788.pdf
University of Washington Medical Center (Applies to WA or OR Medicaid Only)	Transplant	Seattle	WA	Lung	Lung	Adult	Government Rates		Hospital: 200% ofCMS \| Professional: 77% of Billed Charges	N/A		N/A	N/A	Hospital: 200% of CMS \| Professional: 77% of Billed Charges			100% Organ Procurement Organization rate	75% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	788.pdf
University of Washington Medical Center (Applies to WA or OR Medicaid Only)	Transplant	Seattle	WA	Pancreas	Pancreas	Adult	Government Rates		Hospital: 200% ofCMS \| Professional: 77% of Billed Charges	N/A		N/A	N/A	Hospital: 200% of CMS \| Professional: 77% of Billed Charges			100% Organ Procurement Organization rate	75% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	788.pdf
University of Washington Medical Center (Applies to WA or OR Medicaid Only)	Transplant	Seattle	WA	Multi-Organ	Multi-Organ	Adult	Government Rates		Hospital: 200% ofCMS \| Professional: 77% of Billed Charges	N/A		N/A	N/A	Hospital: 200% of CMS \| Professional: 77% of Billed Charges			100% Organ Procurement Organization rate	75% of Billed Charges	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		47.613007	-122.4122753	788.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	Hospital $199,644 \| Professional: $21,641		70% of Billed Charges		90% of Billed Charges	70% of Billed Charges (Lesser of and Stop Loss Apply)	Included in Case Rate	Included in Case Rate			If Billed Charges exceed $202,130 (for Hospital) and $65,686 (for Professional), pay Case Rate plus 50% of excess Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	789.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		Hospital $199,644 \| Professional: $21,641		70% of Billed Charges		90% of Billed Charges	70% of Billed Charges (Lesser of and Stop Loss Apply)	Included in Case Rate	Included in Case Rate			If Billed Charges exceed $202,130 (for Hospital) and $65,686 (for Professional), pay Case Rate plus 50% of excess Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	789.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	Hospital $359,147 \| Professional: $23,628		70% of Billed Charges		90% of Billed Charges	70% of Billed Charges (Lesser of and Stop Loss Apply)	Included in Case Rate	Included in Case Rate			If Billed Charges exceed $718,294 (for Hospital) and $47,256 (for Professional), pay Case Rate plus 50% of excess Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	789.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		Hospital $359,147 \| Professional: $23,628		70% of Billed Charges		90% of Billed Charges	70% of Billed Charges (Lesser of and Stop Loss Apply)	Included in Case Rate	Included in Case Rate			If Billed Charges exceed $718,294 (for Hospital) and $47,256 (for Professional), pay Case Rate plus 50% of excess Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	789.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $125,834 \| Professional: $11,479		70% of Billed Charges		90% of Billed Charges	70% of Billed Charges (Lesser of and Stop Loss Apply)	Included in Case Rate	Included in Case Rate			If Billed Charges exceed $251,668 (for Hospital) and $22,958 (for Professional), pay Case Rate plus 50% of excess Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	789.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		Hospital: $125,834 \| Professional: $11,479		70% of Billed Charges		90% of Billed Charges	70% of Billed Charges (Lesser of and Stop Loss Apply)	Included in Case Rate	Included in Case Rate			If Billed Charges exceed $251,668 (for Hospital) and $22,958 (for Professional), pay Case Rate plus 50% of excess Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	789.pdf
University of Wisconsin Hospital and Clinics	Cancer	Madison	WI	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119															43.084972	-89.4766314	790.pdf
University of Wisconsin Hospital and Clinics	Cellular Immunotherapy	Madison	WI	Cellular Immunotherapy	Cellular Immunotherapy				60% of Billed Charges \| Drug Cost: 110% of Wholesale Acquisition Cost (WAC)	N/A		N/A	N/A	60% of Billed Charges					N/A	Begins at Evaluation and Ends at Admission for CAR-T Therapy Treatment	Begins on the First Day of Admission for CAR-T Cell Therapy Treatment and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	791.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $282,556 \| Professional: $91,421				90% of Billed Charges	70% of Billed Charges (Lesser of and Stop Loss Apply)			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	If Billed Charges exceed $565,112 (for Hospital) and $182,842 (for Professional), pay Case Rate plus 50% of excess Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	792.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Heart	Heart	Pediatric	Programs of Excellence		Hospital: $282,556 \| Professional: $91,421				90% of Billed Charges	70% of Billed Charges (Lesser of and Stop Loss Apply)			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	If Billed Charges exceed $565,112 (for Hospital) and $182,842 (for Professional), pay Case Rate plus 50% of excess Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	792.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	Hospital: $101,065 \| Professional: $32,843				90% of Billed Charges	70% of Billed Charges (Lesser of and Stop Loss Apply)			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	If Billed Charges exceed $202,130 (for Hospital) and $65,686 (for Professional), pay Case Rate plus 50% of excess Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	793.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Kidney	Kidney	Pediatric	Member's Choice		Hospital: $101,065 \| Professional: $32,843				90% of Billed Charges	70% of Billed Charges (Lesser of and Stop Loss Apply)			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	If Billed Charges exceed $202,130 (for Hospital) and $65,686 (for Professional), pay Case Rate plus 50% of excess Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	793.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Kidney/Pancreas	Kidney/Pancreas	Pediatric	Member's Choice		Hospital $179,236 \| Professional: $54,850				90% of Billed Charges	70% of Billed Charges (Lesser of and Stop Loss Apply)			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	If Billed Charges exceed $358,472 (for Hospital) and $109,700 (for Professional), pay Case Rate plus 50% of excess Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	794.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceELITE	Hospital $179,236 \| Professional: $54,850				90% of Billed Charges	70% of Billed Charges (Lesser of and Stop Loss Apply)			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	If Billed Charges exceed $358,472 (for Hospital) and $109,700 (for Professional), pay Case Rate plus 50% of excess Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	794.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor Hospital: $151,965 \| Cadaveric Donor Professional: $103,536 \| Living Donor Hospital: $171,887 \| Living Donor Professional: $143,722				90% of Billed Charges	70% of Billed Charges (Lesser of and Stop Loss Apply)			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	Cadaveric Donor: If Billed Charges exceed $303,912 (for Hospital) and $207,072 (for Professional), pay Case Rate plus 50% of excess Billed Charges \| Living Donor: If Billed Charges exceed $343,774 (for Hospital) and $287,444 (for Professional), pay Case Rate plus 50% of excess Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	795.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Liver	Liver	Pediatric	Member's Choice		Cadaveric Donor Hospital: $151,965 \| Cadaveric Donor Professional: $103,536 \| Living Donor Hospital: $171,887 \| Living Donor Professional: $143,722				90% of Billed Charges	70% of Billed Charges (Lesser of and Stop Loss Apply)			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	Cadaveric Donor: If Billed Charges exceed $303,912 (for Hospital) and $207,072 (for Professional), pay Case Rate plus 50% of excess Billed Charges \| Living Donor: If Billed Charges exceed $343,774 (for Hospital) and $287,444 (for Professional), pay Case Rate plus 50% of excess Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	795.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Heart	Heart	Adult	Government Rates		Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule	N/A		N/A	N/A	Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule			100% of Provider's the Current Medicare D-4 Cost Report for Organ Acquisition	120% of Medicare Allowable Amounts	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		43.084972	-89.4766314	796.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Kidney	Kidney	Adult	Government Rates		Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule	N/A		N/A	N/A	Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule			100% of Provider's the Current Medicare D-4 Cost Report for Organ Acquisition	120% of Medicare Allowable Amounts	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		43.084972	-89.4766314	797.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Kidney/Pancreas	Kidney/Pancreas	Adult	Government Rates		Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule	N/A		N/A	N/A	Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule			100% of Provider's the Current Medicare D-4 Cost Report for Organ Acquisition	120% of Medicare Allowable Amounts	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		43.084972	-89.4766314	798.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Liver	Liver	Adult	Government Rates		Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule	N/A		N/A	N/A	Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule			100% of Provider's the Current Medicare D-4 Cost Report for Organ Acquisition	120% of Medicare Allowable Amounts	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		43.084972	-89.4766314	799.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Lung	Lung	Adult	Government Rates		Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule	N/A		N/A	N/A	Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule			100% of Provider's the Current Medicare D-4 Cost Report for Organ Acquisition	120% of Medicare Allowable Amounts	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		43.084972	-89.4766314	800.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Multi-Organ	Multi-Organ	Adult	Government Rates		Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule	N/A		N/A	N/A	Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule			100% of Provider's the Current Medicare D-4 Cost Report for Organ Acquisition	120% of Medicare Allowable Amounts	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		43.084972	-89.4766314	801.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Pancreas	Pancreas	Adult	Government Rates		Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule	N/A		N/A	N/A	Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule			100% of Provider's the Current Medicare D-4 Cost Report for Organ Acquisition	120% of Medicare Allowable Amounts	N/A	Begins at evaluation	Begins on the Day of Admission and Ends at Discharge	Begins at Discharge and Ends 1 year later		43.084972	-89.4766314	802.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Blood/Marrow (Autologous)	Autologous	Adult	Government Rates		Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule	N/A	N/A	N/A	N/A	Hospital: 120% of Current Medicare DRG with Applicable PassT hroughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule	120% of Medicare Allowable Amount	120% of Medicare Allowable Amount			N/A	Begins at Evaluation	Begins on the Day of Admission for Ablative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		43.084972	-89.4766314	803.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Government Rates		Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule	N/A	N/A	N/A	N/A	Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule	120% of Medicare Allowable Amount	120% of Medicare Allowable Amount			N/A	Begins at Evaluation	Begins on the Day of Admission for Ablative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		43.084972	-89.4766314	803.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Related	Adult	Government Rates		Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule	N/A	N/A	N/A	N/A	Hospital: 120% of Current Medicare DRG with Applicable Pass Throughs \| Professional: 120% of Current Medicare RBRVS Fee Schedule	120% of Medicare Allowable Amount	120% of Medicare Allowable Amount			N/A	Begins at Evaluation	Begins on the Day of Admission for Ablative Therapy and Ends at Discharge	Begins at Discharge and Ends 1-Year Later		43.084972	-89.4766314	803.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Lung	Lung	Adult	Programs of Excellence	PerformanceELITE	Single Lung \| Hospital: $214,804, Professional: $55,522 \| Bilateral Lung \| Hospital: $389,541, Professional: $90,355				90% of Billed Charges	70% of Billed Charges (Lesser of and Stop Loss Apply)			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	Single Lung: If Billed Charges exceed $429,608 (for Hospital) and $111,044 (for Professional), pay Case Rate plus 50% of excess Billed Charges \| Bilateral Lung: If Billed Charges exceed $779,082 (for Hospital) and $180,710 (for Professional), pay Case Rate plus 50% of excess Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	804.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Lung	Lung	Pediatric	Member's Choice		Single Lung \| Hospital: $214,804, Professional: $55,522 \| Bilateral Lung \| Hospital: $389,541, Professional: $90,355				90% of Billed Charges	70% of Billed Charges (Lesser of and Stop Loss Apply)			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	Single Lung: If Billed Charges exceed $429,608 (for Hospital) and $111,044 (for Professional), pay Case Rate plus 50% of excess Billed Charges \| Bilateral Lung: If Billed Charges exceed $779,082 (for Hospital) and $180,710 (for Professional), pay Case Rate plus 50% of excess Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	804.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Multi-Organ	Multi-Organ	Adult	Member's Choice		70% of Billed Charges	N/A			N/A	70% of Billed Charges			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	805.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Multi-Organ	Multi-Organ	Pediatric	Member's Choice		70% of Billed Charges	N/A			N/A	70% of Billed Charges			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	N/A	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	805.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Pancreas	Pancreas	Adult	Programs of Excellence		Hospital $117,366 \| Professional: $32,687				90% of Billed Charges	70% of Billed Charges (Lesser of and Stop Loss Apply)			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	If Billed Charges exceed $234,732 (for Hospital) and $65,374 (for Professional), pay Case Rate plus 50% of excess Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	806.pdf
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Pancreas	Pancreas	Pediatric	Programs of Excellence		Hospital $117,366 \| Professional: $32,687				90% of Billed Charges	70% of Billed Charges (Lesser of and Stop Loss Apply)			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	If Billed Charges exceed $234,732 (for Hospital) and $65,374 (for Professional), pay Case Rate plus 50% of excess Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge		43.084972	-89.4766314	806.pdf
UPMC Children's Hospital of Pittsburgh (University of Pittsburgh Medical Center)	Transplant	Pittsburgh	PA	Kidney	Kidney	Pediatric	Programs of Excellence		Cadaveric Donor: $140,817 \| Living Donor: $194,277	90		Cadaveric Donor: $4,225 \| Living Donor: $5,829 \| (Per Diems also apply to Pre-Transplant Phase)	75% of Billed Charges	Pre-Transplant - Inpatient: The lesser of 75% of Billed Charges or applicable per diems; Outpatient: 70% of Billed Charges \| Post-Transplant - Inpatient: 75% of Billed Charges; Outpatient: 70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	Charges in excess of $281,635 for Cadaveric Donor, or $388,554 for Living Donor, reimbursed at 70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.442532	-79.960175	807.pdf
UPMC Children's Hospital of Pittsburgh (University of Pittsburgh Medical Center)	Transplant	Pittsburgh	PA	Liver	Liver	Pediatric	Programs of Excellence		Cadaveric Donor: $517,162 \| Living Donor: $539,493	90		Cadaveric Donor: $7,956 \| Living Donor: $8,300 \| (Per Diems also apply to Pre-Transplant Phase)	75% of Billed Charges	Pre-Transplant - Inpatient: The lesser of 75% of Billed Charges or applicable per diems; Outpatient: 70% of Billed Charges \| Post-Transplant - Inpatient: 75% of Billed Charges; Outpatient: 70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	Charges in excess of $1,292,905 for Cadaveric Donor, or $1,348,731 for Living Donor, reimbursed at 70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.442532	-79.960175	808.pdf
UPMC Children's Hospital of Pittsburgh (University of Pittsburgh Medical Center)	Transplant	Pittsburgh	PA	Pancreas	Pancreas	Pediatric	Member's Choice		$222,000	90		$4,440 (Per Diems also apply to Pre-Transplant Phase)	75% of Billed Charges	Pre-Transplant - Inpatient: The lesser of 75% of Billed Charges or applicable per diems; Outpatient: 70% of Billed Charges \| Post-Transplant - Inpatient: 75% of Billed Charges; Outpatient: 70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	Charges in excess of $555,000 reimbursed at 70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.442532	-79.960175	809.pdf
UPMC Children's Hospital of Pittsburgh (University of Pittsburgh Medical Center)	Transplant	Pittsburgh	PA	Lung	Lung	Pediatric	Member's Choice		Single: $635,644 \| Bilateral: $659,276	90		Single: $10,037 \| Bilateral: $10,409 \| (Per Diems also apply to Pre-Transplant Phase)	75% of Billed Charges	Pre-Transplant - Inpatient: The lesser of 75% of Billed Charges or applicable per diems; Outpatient: 70% of Billed Charges \| Post-Transplant - Inpatient: 75% of Billed Charges; Outpatient: 70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	Charges in excess of $1,589,111 for Single, or $1,648,189 for Bilateral, reimbursed at 70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.442532	-79.960175	810.pdf
UPMC Children's Hospital of Pittsburgh (University of Pittsburgh Medical Center)	Transplant	Pittsburgh	PA	Kidney/Pancreas	Kidney/Pancreas	Pediatric	Member's Choice		$394,461	90		$6,961 (Per Diems also apply to Pre-Transplant Phase)	75% of Billed Charges	Pre-Transplant - Inpatient: The lesser of 75% of Billed Charges or applicable per diems; Outpatient: 70% of Billed Charges \| Post-Transplant - Inpatient: 75% of Billed Charges; Outpatient: 70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	Charges in excess of $986,154 reimbursed at 70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.442532	-79.960175	811.pdf
UPMC Children's Hospital of Pittsburgh (University of Pittsburgh Medical Center)	Transplant	Pittsburgh	PA	Heart	Heart	Pediatric	Programs of Excellence		$471,131	90		$7,439 (Per Diems also apply to Pre-Transplant Phase)	75% of Billed Charges	Pre-Transplant - Inpatient: The lesser of 75% of Billed Charges or applicable per diems; Outpatient: 70% of Billed Charges \| Post-Transplant - Inpatient: 75% of Billed Charges; Outpatient: 70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	Charges in excess of $1,177,826 reimbursed at 70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.442532	-79.960175	812.pdf
UPMC Children's Hospital of Pittsburgh (University of Pittsburgh Medical Center)	Transplant	Pittsburgh	PA	Multi-Organ	Multi-Organ	Pediatric	Member's Choice		100% of Highest Cost Organ Plus 50% of the Lower Cost Organ	90		100% of Highest Organ per diem (Per Diems also apply to Pre-Transplant Phase)	75% of Billed Charges	Pre-Transplant - Inpatient: The lesser of 75% of Billed Charges or applicable per diems; Outpatient: 70% of Billed Charges \| Post-Transplant - Inpatient: 75% of Billed Charges; Outpatient: 70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	Charges in excess of Threshold (2.5x Highest Case Rate) reimbursed at 70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.442532	-79.960175	813.pdf
UPMC Children's Hospital of Pittsburgh (University of Pittsburgh Medical Center)	Transplant	Pittsburgh	PA	Intestine	Intestine	Pediatric	Programs of Excellence		70% of Billed Charges	N/A		N/A					Included in Case Rate	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.442532	-79.960175	814.pdf
UPMC Harrisburg (University of Pittsburgh Medical Center)	Transplant	Harrisburg	PA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor: $140,817 \| Living Donor: $194,277	90		Cadaveric Donor: $4,225 \| Living Donor: $5,829 \| (Per Diems also apply to Pre-Transplant Phase)	75% of Billed Charges	Pre-Transplant - Inpatient: The lesser of 75% of Billed Charges or applicable per diems; Outpatient: 70% of Billed Charges \| Post-Transplant - Inpatient: 75% of Billed Charges; Outpatient: 70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	Charges in excess of $281,635 for Cadaveric Donor, or $388,554 for Living Donor, reimbursed at 70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.25806	-76.88	815.pdf
UPMC Presbyterian Shadyside (University of Pittsburgh Medical Center)	Transplant	Pittsburgh	PA	Kidney	Kidney	Adult	Member's Choice		Cadaveric Donor: $140,817 \| Living Donor: $194,277	90		Cadaveric Donor: $4,225 \| Living Donor: $5,829 \| (Per Diems also apply to Pre-Transplant Phase)	75% of Billed Charges	Pre-Transplant - Inpatient: The lesser of 75% of Billed Charges or applicable per diems; Outpatient: 70% of Billed Charges \| Post-Transplant - Inpatient: 75% of Billed Charges; Outpatient: 70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	Charges in excess of $281,635 for Cadaveric Donor, or $388,554 for Living Donor, reimbursed at 70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.442532	-79.960175	816.pdf
UPMC Presbyterian Shadyside (University of Pittsburgh Medical Center)	Transplant	Pittsburgh	PA	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor: $517,162 \| Living Donor: $539,493	90		Cadaveric Donor: $7,956 \| Living Donor: $8,300 \| (Per Diems also apply to Pre-Transplant Phase)	75% of Billed Charges	Pre-Transplant - Inpatient: The lesser of 75% of Billed Charges or applicable per diems; Outpatient: 70% of Billed Charges \| Post-Transplant - Inpatient: 75% of Billed Charges; Outpatient: 70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	Charges in excess of $1,292,905 for Cadaveric Donor, or $1,348,731 for Living Donor, reimbursed at 70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.442532	-79.960175	817.pdf
UPMC Presbyterian Shadyside (University of Pittsburgh Medical Center)	Transplant	Pittsburgh	PA	Pancreas	Pancreas	Adult	Member's Choice		$222,000	90		$4,440 (Per Diems also apply to Pre-Transplant Phase)	75% of Billed Charges	Pre-Transplant - Inpatient: The lesser of 75% of Billed Charges or applicable per diems; Outpatient: 70% of Billed Charges \| Post-Transplant - Inpatient: 75% of Billed Charges; Outpatient: 70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	Charges in excess of $555,000 reimbursed at 70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.442532	-79.960175	818.pdf
UPMC Presbyterian Shadyside (University of Pittsburgh Medical Center)	Transplant	Pittsburgh	PA	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	Single: $635,644 \| Bilateral: $659,276	90		Single: $10,037 \| Bilateral: $10,409 \| (Per Diems also apply to Pre-Transplant Phase)	75% of Billed Charges	Pre-Transplant - Inpatient: The lesser of 75% of Billed Charges or applicable per diems; Outpatient: 70% of Billed Charges \| Post-Transplant - Inpatient: 75% of Billed Charges; Outpatient: 70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	Charges in excess of $1,589,111 for Single, or $1,648,189 for Bilateral, reimbursed at 70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.442532	-79.960175	819.pdf
UPMC Presbyterian Shadyside (University of Pittsburgh Medical Center)	Transplant	Pittsburgh	PA	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$394,461	90		$6,961 (Per Diems also apply to Pre-Transplant Phase)	75% of Billed Charges	Pre-Transplant - Inpatient: The lesser of 75% of Billed Charges or applicable per diems; Outpatient: 70% of Billed Charges \| Post-Transplant - Inpatient: 75% of Billed Charges; Outpatient: 70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	Charges in excess of $986,154 reimbursed at 70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.442532	-79.960175	820.pdf
UPMC Presbyterian Shadyside (University of Pittsburgh Medical Center)	Transplant	Pittsburgh	PA	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$471,131	90		$7,439 (Per Diems also apply to Pre-Transplant Phase)	75% of Billed Charges	Pre-Transplant - Inpatient: The lesser of 75% of Billed Charges or applicable per diems; Outpatient: 70% of Billed Charges \| Post-Transplant - Inpatient: 75% of Billed Charges; Outpatient: 70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	Charges in excess of $1,177,826 reimbursed at 70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.442532	-79.960175	821.pdf
UPMC Presbyterian Shadyside (University of Pittsburgh Medical Center)	Transplant	Pittsburgh	PA	Multi-Organ	Multi-Organ	Adult	Member's Choice		100% of Highest Cost Organ Plus 50% of the Lower Cost Organ	90		100% of Highest Organ per diem (Per Diems also apply to Pre-Transplant Phase)	75% of Billed Charges	Pre-Transplant - Inpatient: The lesser of 75% of Billed Charges or applicable per diems; Outpatient: 70% of Billed Charges \| Post-Transplant - Inpatient: 75% of Billed Charges; Outpatient: 70% of Billed Charges			Included in Case Rate	100% of Invoice Cost	Charges in excess of Threshold (2.5x Highest Case Rate) reimbursed at 70% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.442532	-79.960175	822.pdf
UPMC Presbyterian Shadyside (University of Pittsburgh Medical Center)	Transplant	Pittsburgh	PA	Intestine	Intestine	Adult	Member's Choice		70% of Billed Charges	N/A		N/A					Included in Case Rate	100% of Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge		40.442532	-79.960175	823.pdf
UT Southwestern Medical Center	Transplant	Dallas	TX	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$77,000	25		$2,300 Med/Surg \| $2,900 ICU/CCU	80% of Billed Charges	80% of Billed Charges	Included in Case Rate	N/A			50% of Billed Charges	Begins at Evaluation	Begins on the First Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		32.8205862	-96.871968	824.pdf
UT Southwestern Medical Center	Transplant	Dallas	TX	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$119,000	30		$2,300 Med/Surg \| $2,900 ICU/CCU	80% of Billed Charges	80% of Billed Charges	Included in Case Rate	N/A			50% of Billed Charges	Begins at Evaluation	Begins on the First Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		32.8205862	-96.871968	824.pdf
UT Southwestern Medical Center	Transplant	Dallas	TX	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$155,000	35		$2,300 Med/Surg \| $2,900 ICU/CCU	80% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the First Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		32.8205862	-96.871968	824.pdf
UT Southwestern Medical Center	Transplant	Dallas	TX	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceQUALITY	$109,000 (Includes Both Cycles)	40 (20 per Cycle)		$2,300 Med/Surg \| $2,900 ICU/CCU	80% of Billed Charges	80% of Billed Charges	Included in Case Rate				50% of Billed Charges	Begins at Evaluation	Begins on the First Day of Ablative Therapy and Ends when the Inlier Days have Expired	Ends One (1) Year from Discharge		32.8205862	-96.871968	824.pdf
UT Southwestern Medical Center	Transplant	Dallas	TX	Cord Blood	Cord Blood	Adult	Programs of Excellence	PerformanceQUALITY	75% of Billed Charges	N/A		N/A	N/A	80% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins on the First Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge		32.8205862	-96.871968	824.pdf
UT Southwestern Medical Center	Transplant	Dallas	TX	Heart/Kidney	Heart/Kidney	Adult	Member's Choice		65% of Billed Charges	N/A		N/A	80% of Billed Charges	80% of Billed Charges			Reimbursed at Standard Acquisition Charge not to Exceed OPO Invoice Cost, Plus 45%	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		32.8205862	-96.871968	825.pdf
UT Southwestern Medical Center	Transplant	Dallas	TX	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		65% of Billed Charges	N/A		N/A	N/A	80% of Billed Charges			Reimbursed at Standard Acquisition Charge not to Exceed OPO Invoice Cost, Plus 45%	Reimbursed at Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		32.8205862	-96.871968	826.pdf
UT Southwestern Medical Center	Transplant	Dallas	TX	Heart & Lung	Heart/Lung	Adult	Member's Choice		$175,000	35		$2,300 Med/Surg \| $2,900 ICU/CCU	80% of Billed Charges	80% of Billed Charges			Reimbursed at Standard Acquisition Charge not to Exceed OPO Invoice Cost, Plus 45%	Reimbursed at Invoice Cost	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		32.8205862	-96.871968	827.pdf
UT Southwestern Medical Center	Transplant	Dallas	TX	Pancreas	Pancreas	Adult	Programs of Excellence		$75,000	15		$2,300 Med/Surg \| $2,900 ICU/CCU	80% of Billed Charges	80% of Billed Charges			Reimbursed at Standard Acquisition Charge not to Exceed OPO Invoice Cost, Plus 45%	Reimbursed at Invoice Cost	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		32.8205862	-96.871968	828.pdf
UT Southwestern Medical Center	Transplant	Dallas	TX	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$110,000	25		$2,300 Med/Surg \| $2,900 ICU/CCU	80% of Billed Charges	80% of Billed Charges			Reimbursed at Standard Acquisition Charge not to Exceed OPO Invoice Cost, Plus 45%	Reimbursed at Invoice Cost	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		32.8205862	-96.871968	829.pdf
UT Southwestern Medical Center	Destination VAD	Dallas	TX	Destination VAD	Destination VAD				Surgical Event: 75% of Billed Charges	N/A		N/A	N/A	80% of Billed Charges \| VAD Maintenance & Supplies: 110% of Medicare Reimbursement				100% of Invoice Cost	N/A	Begins at Evaluation and Ends on the Day of VAD Insertion	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		32.8205862	-96.871968	829.pdf
UT Southwestern Medical Center	Transplant	Dallas	TX	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	$55,000	14		$2,300 Med/Surg \| $2,900 ICU/CCU	80% of Billed Charges	80% of Billed Charges			Reimbursed at Standard Acquisition Charge not to Exceed OPO Invoice Cost, Plus 45%	Reimbursed at Invoice Cost	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		32.8205862	-96.871968	830.pdf
UT Southwestern Medical Center	Transplant	Dallas	TX	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	$125,000	15		$2,300 Med/Surg \| $2,900 ICU/CCU	80% of Billed Charges	80% of Billed Charges			Reimbursed at Standard Acquisition Charge not to Exceed OPO Invoice Cost, Plus 45%	Reimbursed at Invoice Cost	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		32.8205862	-96.871968	831.pdf
UT Southwestern Medical Center	Transplant	Dallas	TX	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	$140,000	35		$2,300 Med/Surg \| $2,900 ICU/CCU	80% of Billed Charges	80% of Billed Charges			Reimbursed at Standard Acquisition Charge not to Exceed OPO Invoice Cost, Plus 45%	Reimbursed at Invoice Cost	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge		32.8205862	-96.871968	832.pdf
UT Southwestern Medical Center	Transplant	Dallas	TX	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$85,000	20		$2,300 Med/Surg \| $2,900 ICU/CCU	80% of Billed Charges	80% of Billed Charges			Reimbursed at Standard Acquisition Charge not to Exceed OPO Invoice Cost, Plus 45%	Reimbursed at Invoice Cost	50% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge		32.8205862	-96.871968	833.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Heart/Lung	Heart/Lung	Adult	Member's Choice		$407,763	N/A		N/A	95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Charges Exceed $1,141,737, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	834.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	$243,901	N/A			95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Charges Exceed $582,922, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins on Day of Transplantation and Ends at Discharge	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	835.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Pancreas	Pancreas	Adult	Programs of Excellence		$156,832	N/A			95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Charges Exceed $439,130, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins on Day of Transplantation and Ends at Discharge	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	836.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	Inpatient: $124,384 \| Outpatient: $113,568	Inpatient: N/A \| Outpatient: 30		N/A	95% of Billed Charges	70% of Billed Charges	Included in Case Rate				If Charges Exceed $348,275 for Inpatient, or $317,990 for Outpatient, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins One Day Prior to Ablative Therapy and Ends at Discharge for Inpatient Transplant and Ends When Inlier Days have Elapsed for Outpatient Transplants	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	837.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	Related Inpatient: $205,504 \| Related Outpatient: $184,954 \| Non-Myeloablative: $189,280 \| Haplo $218,483	Related Inpatient: 20 \| Related Outpatient: 30 \| Non-Myeloablative: 20 \| Haplo: 30	Transplant Period Begins on Day of Mobilization or Preparative Therapy and Ends when Allowable Days have Elapsed	N/A	95% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			If Charges Exceed $575,411 for Inpatient, or $517,870 for Outpatient, or $529,984 for Non Myeloablative, or $611,753 for Haplo, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins One Day Prior to Ablative Therapy and Ends at Discharge for Inpatient Transplant and Ends When Inlier Days have Elapsed	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	837.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	Inpatient: $218,483 \| Outpatient: $205,504 \| Haplo: $218,483	Inpatient: N/A \| Outpatient: 30 \| Haplo: 30	If Patient is Admitted Within the Inlier Period, Transplant Period Ends the Later of Discharge or End of Inlier Days.	N/A	95% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			If Charges Exceed $611,753 for Inpatient, or $575,411 for Outpatient, or $611,753 for Haplo, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins One Day Prior to Ablative Therapy and Ends at Discharge for Inpatient Transplant and Ends When Inlier Days have Elapsed for Outpatient Transplants	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	837.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Tandem (Auto-to-Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceSELECT	$235,789	Inpatient: 20 \| Outpatient: 30	Begins on the Date of Mobilization or Preparative Therapy and Concludes when the Allowable Days have Elapsed	70% of Billed Charges	95% of Billed Charges	70% of Billed Charges	Included in Case Rate				If Charges Exceed $661,723, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		36.1865585	-86.9256707	837.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Blood/Marrow (Tandem Auto to Related Allo)	Tandem Auto to Allo	Adult	Programs of Excellence	PerformanceSELECT	$342,867	Inpatient Autologous: 20 \| OutpatientAutologous: 30 \| Inpatient Allogeneic: 20 \| Outpatient Allogeneic: 30 \| Allogeneic Haplo: 20	Begins on the Date of Mobilization or Preparative Therapy and Concludes when the Allowable Days have Elapsed	70% of Billed Charges	95% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			If Charges Exceed $960,028, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		36.1865585	-86.9256707	837.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Cord Blood	Cord Blood	Adult	Programs of Excellence	PerformanceSELECT	Single: $243,360 \| Double: $270,400	Single: 20 \| Double: 30	Transplant Period Begins on Day of Mobilization or Preparative Therapy and Ends when Allowable Days have Elapsed	N/A	95% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			If Charges Exceed $681,408 for Single, or $757,120 for Double, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier have Expired	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	837.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$248,768	N/A			95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Charges Exceed $696,550, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins on Day of Transplantation and Ends at Discharge	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	838.pdf
Vanderbilt University Medical Center	Destination VAD	Nashville	TN	Destination VAD	Destination VAD				Adult: $135,200 \| Pediatric: $168,730	N/A		N/A	95% of Billed Charges	70% of Billed Charges \| VAD Maintenance & Supplies: 70% of Billed Charges				55% of Billed Charges	If Charges Exceed $378,560 (for Adult) or $421,824 (for Pediatric), Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation and Ends on the Day of VAD Insertion Admission	Begins on the Day of VAD Insertion and Ends at Discharge	Begins at Discharge and Remains Active Until: \| (a) The Death of the Patient \| (b) Patient's Insurance Coverage Terminates \| (c )If Patient Receives a Heart Transplant		36.1865585	-86.9256707	838.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$124,384	N/A			95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Charges Exceed $348,275, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins on Day of Transplantation and Ends at Discharge	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	839.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		$309,878	N/A			95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Charges Exceed $867,660, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins on Day of Transplantation and Ends at Discharge	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	840.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	$222,810	N/A			95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Charges Exceed $623,867, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins on Day of Transplantation and Ends at Discharge	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	841.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Lung	Lung	Adult	Programs of Excellence	PerformanceELITE	Single Lung: $227,136 \| Bilateral Lung: $242,278	N/A			95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Charges Exceed $635,981 for Single Lung, or $678,380 for Bilateral Lung, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins on Day of Transplantation and Ends at Discharge	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	842.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Multi-Organ	Multi-Organ	Adult	Member's Choice		100% of Highest Cost Organ Plus 70% of the Lower Cost Organ	N/A			95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Charges Exceed 100% of the higher organ threshold rate plus 70% of the lower organ threshold rate, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins on Day of Transplantation and Ends at Discharge	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	843.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$136,282	20		N/A	95% of Billed Charges	70% of Billed Charges	Included in Case Rate	N/A			If Charges Exceed $340,704, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	844.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		Related: $232,544 \| Non-Myeloablative: $210,912 \| Haplo: $259,584	Related: 20 \| Non-Myeloablative: 20 \| Haplo: 30		N/A	95% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			If Charges Exceed $581,360 (Related) $527,280 (Non-Myeloablative) $648,960 (Haplo), Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins One Day Prior to Ablative Therapy and Ends at Discharge for Inpatient Transplant and Ends When Inlier Days have Elapsed for Outpatient Transplants	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	844.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		Unrelated: $259,584 \| Haplo: $259,584	Unrelated: 20 \| Haplo: 30		N/A	95% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			If Charges Exceed $648,960, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins One Day Prior to Ablative Therapy and Ends at Discharge for Inpatient Transplant and Ends When Inlier Days have Elapsed for Outpatient Transplants	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	844.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Cord Blood	Cord Blood	Pediatric	Programs of Excellence		Single: $283,379 \| Double: $319,072	20	Transplant Period Begins on Day of Mobilization or Preparative Therapy and Ends when Allowable Days have Elapsed	N/A	95% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			If Charges Exceed $708,448 for Single, or $797,680 for Double, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier have Expired	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	844.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Tandem (Auto-to-Auto)	Tandem Auto to Auto	Pediatric	Programs of Excellence		$258,935	20	Begins on the Date of Mobilization or Preparative Therapy and Concludes when the Allowable Days have Elapsed	70% of Billed Charges	95% of Billed Charges	70% of Billed Charges	Included in Case Rate				If Charges Exceed $647,338, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		36.1865585	-86.9256707	844.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Blood/Marrow (Tandem Auto to Related Allo)	Tandem Auto to Allo	Pediatric	Programs of Excellence		$395,866	Inpatient Allogeneic: 20 \| Non-Myeloablative Allogeneic: 20 \| Allogeneic Haplo: 30\| Autologous: 20	Begins on the Date of Mobilization or Preparative Therapy and Concludes when the Allowable Days have Elapsed	70% of Billed Charges	95% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			If Charges Exceed $989,664, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		36.1865585	-86.9256707	844.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Heart	Heart	Pediatric	Programs of Excellence		(0 - 4 Years): $286,624 \| (5 - 17 Years): $259,584	N/A			95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Charges Exceed $716,560 (0-4 Years), or $648,960 (5-17 Years), Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins on Day of Transplantation and Ends at Discharge	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	845.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Kidney	Kidney	Pediatric	Programs of Excellence		$140,608	N/A			95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Charges Exceed $351,520, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins on Day of Transplantation and Ends at Discharge	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	846.pdf
Vanderbilt University Medical Center	Transplant	Nashville	TN	Liver	Liver	Pediatric	Programs of Excellence		$268,237	N/A			95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 55% of Billed Charges	If Charges Exceed $670,592, Payment will be the Case Rate, Plus 60% of the Excess Charges	Begins at Evaluation	Begins on Day of Transplantation and Ends at Discharge	Ends 365 Days from Conclusion of Transplant Period		36.1865585	-86.9256707	847.pdf
Washington Hospital Center	Transplant	Washington, DC	DC	Heart	Heart	Adult	Member's Choice		$175,000	25		$3,000 Med/Surg \| $3,500 ICU/CCU	95% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at 70% of Billed Charges	If Billed Charges Exceed $300,000, Payment will be the Transplant Case Rate plus any applicable Outlier Days, Plus 65% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Inlier and applicable Outlier Days		38.8937091	-77.0846157	848.pdf
Yale New Haven Hospital	Transplant	New haven	CT	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$130,000	35	Provisions the same as Inpatient	$2,500 Med/Surg \| $3,000 ICU/CCU	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		41.2983476	-72.9641153	849.pdf
Yale New Haven Hospital	Transplant	New haven	CT	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$169,000	38	Provisions the same as Inpatient	$2,500 Med/Surg \| $3,000 ICU/CCU	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		41.2983476	-72.9641153	849.pdf
Yale New Haven Hospital	Transplant	New haven	CT	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$93,000	30	Provisions the same as Inpatient	$2,500 Med/Surg \| $3,000 ICU/CCU	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		41.2983476	-72.9641153	849.pdf
Yale New Haven Hospital	Transplant	New haven	CT	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Member's Choice		$130,000	35	Provisions the same as Inpatient	$2,500 Med/Surg \| $3,000 ICU/CCU	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		41.2983476	-72.9641153	849.pdf
Yale New Haven Hospital	Transplant	New haven	CT	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Member's Choice		$169,000	38	Provisions the same as Inpatient	$2,500 Med/Surg \| $3,000 ICU/CCU	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		41.2983476	-72.9641153	849.pdf
Yale New Haven Hospital	Transplant	New haven	CT	Blood/Marrow (Autologous)	Autologous	Pediatric	Member's Choice		$93,000	30	Provisions the same as Inpatient	$2,500 Med/Surg \| $3,000 ICU/CCU	90% of Billed Charges	80% of Billed Charges	Included in Case Rate	Included in Case Rate			60% of Billed Charges	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge		41.2983476	-72.9641153	849.pdf
Yale New Haven Hospital	Transplant	New haven	CT	Heart	Heart	Pediatric	Member's Choice		$150,000	18		$2,500 Med/Surg \| $3,000 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends 365 Days from Discharge		41.2983476	-72.9641153	850.pdf
Yale New Haven Hospital	Transplant	New haven	CT	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$150,000	18		$2,500 Med/Surg \| $3,000 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends 365 Days from Discharge		41.2983476	-72.9641153	850.pdf
Yale New Haven Hospital	Transplant	New haven	CT	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor: $72,000 \| Living Donor: $78,000	12		$2,500 Med/Surg \| $3,000 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate		60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends 365 Days from Discharge		41.2983476	-72.9641153	851.pdf
Yale New Haven Hospital	Transplant	New haven	CT	Kidney	Kidney	Pediatric	Member's Choice		Cadaveric Donor: $72,000 \| Living Donor: $78,000	12		$2,500 Med/Surg \| $3,000 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate		60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends 365 Days from Discharge		41.2983476	-72.9641153	851.pdf
Yale New Haven Hospital	Transplant	New haven	CT	Pancreas	Pancreas	Adult	Member's Choice		$75,000	12		$2,500 Med/Surg \| $3,000 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate		60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends 365 Days from Discharge		41.2983476	-72.9641153	852.pdf
Yale New Haven Hospital	Transplant	New haven	CT	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$101,000	18		$2,500 Med/Surg \| $3,000 ICU/CCU	90% of Billed Charges	80% of Billed Charges			Included in Case Rate		60% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier and any Applicable Outlier Days have Expired Ends One Year from the End of the Transplant Phase	Ends 365 Days from Discharge		41.2983476	-72.9641153	853.pdf

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