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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
University of Alabama Hospital	Transplant	Birmingham	AL	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$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
University of Alabama Hospital	Transplant	Birmingham	AL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		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
University of Alabama Hospital	Transplant	Birmingham	AL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$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
University of Alabama Hospital	Transplant	Birmingham	AL	Heart	Heart	Adult	Programs of Excellence	PerformanceELITE	$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
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
University of Alabama Hospital	Transplant	Birmingham	AL	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$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
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
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
University of Alabama Hospital	Transplant	Birmingham	AL	Lung	Lung	Adult	Member's Choice		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
University of Alabama Hospital	Transplant	Birmingham	AL	Pancreas	Pancreas	Adult	Member's Choice		$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
University of Alabama Hospital	Transplant	Birmingham	AL	Heart	Heart	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
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
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
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
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
University of Arkansas for Medical Sciences (UAMS)	Transplant	Little Rock	AR	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$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
University of Arkansas for Medical Sciences (UAMS)	Transplant	Little Rock	AR	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$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
University of Arkansas for Medical Sciences (UAMS)	Transplant	Little Rock	AR	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$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
University of Arkansas for Medical Sciences (UAMS)	Transplant	Little Rock	AR	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Member's Choice		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
University of Arkansas for Medical Sciences (UAMS)	Transplant	Little Rock	AR	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Adult	Member's Choice		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
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
University of Arkansas for Medical Sciences (UAMS)	Transplant	Little Rock	AR	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$100,000	20		$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
University of Arkansas for Medical Sciences (UAMS)	Transplant	Little Rock	AR	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	$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
University of Arkansas for Medical Sciences (UAMS)	Transplant	Little Rock	AR	Pancreas	Pancreas	Adult	Member's Choice		$75,000	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
Mayo Clinic Hospital (Arizona)	Transplant	Phoenix	AZ	Heart	Heart	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
Mayo Clinic Hospital (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
Mayo Clinic Hospital (Arizona)	Transplant	Phoenix	AZ	Kidney/Pancreas	Kidney/Pancreas	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
Mayo Clinic Hospital (Arizona)	Transplant	Phoenix	AZ	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	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
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
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
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
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
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
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
St Joseph's Hospital and Medical Center	Transplant	Phoenix	AZ	Kidney	Kidney	Adult	Member's Choice		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
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
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
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$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 Discharge
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$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 Discharge
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$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 Discharge
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 when Inlier and Ends upon Discharge	Ends 365 Days from Discharge
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 when Inlier and Ends upon Discharge	Ends 365 Days from Discharge
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$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 when Inlier and Ends upon Discharge	Ends 365 Days from Discharge
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 when Inlier and Ends upon Discharge	Ends 365 Days from Discharge
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 when Inlier and Ends upon Discharge	Ends 365 Days from Discharge
Cedars-Sinai Medical Center	Transplant	Los Angeles	CA	Lung	Lung	Adult	Member's Choice		$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 when Inlier and Ends upon Discharge	Ends 365 Days from Discharge
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 when Inlier and Ends upon Discharge	Ends 365 Days from Discharge
Children's Hospital Los Angeles	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		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
Children's Hospital Los Angeles	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		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
Children's Hospital Los Angeles	Transplant	Los Angeles	CA	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		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
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
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
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
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
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
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
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
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
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
Keck Hospital of USC	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	$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
Keck Hospital of USC	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	$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
Keck Hospital of USC	Transplant	Los Angeles	CA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	$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
Keck Hospital of USC	Transplant	Los Angeles	CA	Heart	Heart	Adult	Programs of Excellence	PerformanceELITE	$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
Keck Hospital of USC	Transplant	Los Angeles	CA	Heart/Lung	Heart/Lung	Adult	Member's Choice		$1897,50	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
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
Keck Hospital of USC	Transplant	Los Angeles	CA	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	$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
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
Keck Hospital of USC	Transplant	Los Angeles	CA	Lung	Lung	Adult	Member's Choice		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
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
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
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
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
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
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
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
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
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
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
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
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
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
Scripps Green Hospital	Transplant	San Diego		Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$125,000	N/A	Begin on the First Day of Ablative Therapy Through the Date of last Infusion	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
Scripps Green Hospital	Transplant	San Diego		Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$140,000	N/A	Begin on the First Day of Ablative Therapy Through the Date of last Infusion	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
Scripps Green Hospital	Transplant	San Diego	CA	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$80,000	N/A	Begin on the First Day of Ablative Therapy Through the Date of last Infusion	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
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
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
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
Scripps Green Hospital	Transplant	San Diego	CA	Pancreas	Pancreas	Adult	Member's Choice		$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
Stanford Health Care	Transplant	Palo Alto	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	$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
Stanford Health Care	Transplant	Palo Alto	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	$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
Stanford Health Care	Transplant	Palo Alto	CA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	$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
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
Stanford Health Care	Transplant	Palo Alto	CA	Kidney	Kidney	Adult	Member's Choice		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
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
Stanford Health Care	Transplant	Palo Alto	CA	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	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
Stanford Health Care	Transplant	Palo Alto	CA	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	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
Stanford Health Care	Transplant	Palo Alto	CA	Pancreas	Pancreas	Adult	Member's Choice		$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
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		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 525% 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
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		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 525% 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
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		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 525% 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
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	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 525% 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
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
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
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 525% 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
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 525% 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
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 525% 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
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Liver	Liver	Adult	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 525% 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
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 525% 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
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Multi-Visceral	Multi-Visceral	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 525% 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
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Pancreas	Pancreas	Adult	Member's Choice		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 525% 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
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 525% 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
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 525% 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
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 525% 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
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 525% 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
University of California at Los Angeles Medical Center	Transplant	Los Angeles	CA	Intestine	Intestine	Pediatric	Programs of Excellence		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 525% 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
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 525% 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
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 525% 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
University of California San Diego Medical Center	Transplant	San Diego	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $139,100 \| Professional: $21,400	35	Begins on the First Day of Ablative Therapy and Ends on the Date of the last Infusion	N/A	80% of Billed Charges	65% of Billed Charges	Included in the Case Rate	Included in the Case Rate	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
University of California San Diego Medical Center	Transplant	San Diego	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $214,000 \| Professional: $32,100	40	Begins on the First Day of Ablative Therapy and Ends on the Date of the last Infusion	N/A	80% of Billed Charges	65% of Billed Charges	Included in the Case Rate	Included in the Case Rate	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
University of California San Diego Medical Center	Transplant	San Diego	CA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $90,950 \| Professional: $16,050	30	Begins on the First Day of Ablative Therapy and Ends on the Date of the last Infusion	N/A	80% of Billed Charges	65% of Billed Charges	Included in the Case Rate	Included in the Case Rate	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
University of California San Diego Medical Center	Transplant	San Diego	CA	Heart	Heart	Adult	Programs of Excellence	PerformanceELITE	Hospital: $149,800 \| Professional: $37,450	30		N/A	80% of Billed Charges	65% of Billed Charges			Included in Case Rate	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
University of California San Diego Medical Center	Transplant	San Diego	CA	Heart/Kidney	Heart/Kidney	Adult	Member's Choice		Hospital: $193,670 \| Professional: $45,475	30		N/A	80% of Billed Charges	65% of Billed Charges			Included in Case Rate	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
University of California San Diego Medical Center	Transplant	San Diego	CA	Heart/Lung	Heart/Lung	Adult	Member's Choice		Hospital: $192,600 \| Professional: $53,500	30		N/A	80% of Billed Charges	65% of Billed Charges			Included in Case Rate	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
University of California San Diego Medical Center	Transplant	San Diego	CA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $87,740 \| Professional: $16,050	9		N/A	80% of Billed Charges	65% of Billed Charges			Included in Case Rate	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
University of California San Diego Medical Center	Transplant	San Diego	CA	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		Hospital: $215,070 \| Professional: $50,825	30		N/A	80% of Billed Charges	65% of Billed Charges			Included in Case Rate	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
University of California San Diego Medical Center	Transplant	San Diego	CA	Kidney/Lung	Kidney/Lung	Adult	Member's Choice		Hospital: $204,370 \| Professional: $50,825	30		N/A	80% of Billed Charges	65% of Billed Charges			Included in Case Rate	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
University of California San Diego Medical Center	Transplant	San Diego	CA	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		Hospital: $107,000 \| Professional: $32,100	15		N/A	80% of Billed Charges	65% of Billed Charges			Included in Case Rate	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
University of California San Diego Medical Center	Transplant	San Diego	CA	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $171,200 \| Professional: $42,800	30		N/A	80% of Billed Charges	65% of Billed Charges			Included in Case Rate	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
University of California San Diego Medical Center	Transplant	San Diego	CA	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $160,500 \| Professional: $42,800	30		N/A	80% of Billed Charges	65% of Billed Charges			Included in Case Rate	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
University of California San Diego Medical Center	Transplant	San Diego	CA	Pancreas	Pancreas	Adult	Member's Choice		Hospital: $90,950 \| Professional: $16,050	15		N/A	80% of Billed Charges	65% of Billed Charges			Included in Case Rate	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
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	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
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	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
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	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
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	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
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
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	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
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		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
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	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
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
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
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
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
University of California San Francisco Medical Center	Transplant	San Francisco	CA	Kidney	Kidney	Pediatric	Member's Choice		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
University of California San Francisco Medical Center	Transplant	San Francisco	CA	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	Ends One Year from Discharge
Children's Hospital Colorado	Transplant	Aurora	CO	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$184,450	35	Provisions the same as Inpatient	$5,534	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
Children's Hospital Colorado	Transplant	Aurora	CO	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$210,800	35	Provisions the same as Inpatient	$5,534	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
Children's Hospital Colorado	Transplant	Aurora	CO	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$152,830	30	Provisions the same as Inpatient	$5,534	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
Children's Hospital Colorado	Transplant	Aurora	CO	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Pediatric	Programs of Excellence		$263,500	30 for each Auto	Provisions the same as Inpatient	$5,534	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
Children's Hospital Colorado	Transplant	Aurora	CO	Heart	Heart	Pediatric	Programs of Excellence		$184,450	20		$5,534	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
Children's Hospital Colorado	Transplant	Aurora	CO	Kidney	Kidney	Pediatric	Programs of Excellence		$65,348	14		$5,534	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
Children's Hospital Colorado	Transplant	Aurora	CO	Liver	Liver	Pediatric	Programs of Excellence		$183,396	25		$5,534	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
Porter Adventist Hospital	Transplant	Denver	CO	Kidney	Kidney	Adult	Member's Choice		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
Porter Adventist Hospital	Transplant	Denver	CO	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$68,000	25		$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
Porter Adventist Hospital	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
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
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
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
University of Colorado Hospital	Transplant	Aurora	CO	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$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 One Year from the End of the Transplant Phase	Ends 365 Days from Discharge
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 One Year from the End of the Transplant Phase	Ends 365 Days from Discharge
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 One Year from the End of the Transplant Phase	Ends 365 Days from Discharge
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 One Year from the End of the Transplant Phase	Ends 365 Days from Discharge
University of Colorado Hospital	Transplant	Aurora	CO	Lung	Lung	Adult	Member's Choice		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 One Year from the End of the Transplant Phase	Ends 365 Days from Discharge
University of Colorado Hospital	Transplant	Aurora	CO	Pancreas	Pancreas	Adult	Member's Choice		$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 One Year from the End of the Transplant Phase	Ends 365 Days from Discharge
Yale New haven Hospital	Transplant	New haven	CT	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	$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
Yale New haven Hospital	Transplant	New haven	CT	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	$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
Yale New haven Hospital	Transplant	New haven	CT	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	$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
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
Yale New haven Hospital	Transplant	New haven	CT	Kidney	Kidney	Adult	Programs of Excellence		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
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
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
Ge.orgetown University Medical Center	Transplant	Washington, DC	DC	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$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 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 One Year from the End of the Transplant Phase	Ends 365 Days from Discharge
Ge.orgetown University Medical Center	Transplant	Washington, DC	DC	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceELITE	$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 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 One Year from the End of the Transplant Phase	Ends 365 Days from Discharge
Ge.orgetown University Medical Center	Transplant	Washington, DC	DC	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	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 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 One Year from the End of the Transplant Phase	Ends 365 Days from Discharge
Ge.orgetown University Medical Center	Transplant	Washington, DC	DC	Pancreas	Pancreas	Adult	Member's Choice		$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 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 One Year from the End of the Transplant Phase	Ends 365 Days from Discharge
Ge.orgetown University Medical Center	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 One Year from the End of the Transplant Phase	Ends 365 Days from Discharge
Ge.orgetown University Medical Center	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 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 One Year from the End of the Transplant Phase	Ends 365 Days from Discharge
Ge.orgetown University Medical Center	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 One Year from the End of the Transplant Phase	Ends 365 Days from Discharge
Washington Hospital Center	Transplant	Washington, DC	DC	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$175,000	25		$3,0000Med/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 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 One Year from the End of the Transplant Phase	Ends 365 Days from Discharge
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
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
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
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
Broward General Medical Center	Transplant	Fort Lauderdale	FL	Liver	Liver	Adult	Member's Choice		Hospital: $160,000 \| Professional: 70% of Billed Charges	25		$2,000 Med/Surg \| $3,000 ICU/CCU	80% of Billed Charges	Hospital: 80% of Billed Charges \| Professional: 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
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$170,222	30	Provisions the same as Inpatient	$2,979 Med/Surg \| $3,262 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
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$187,352	35	Provisions the same as Inpatient	$2,979 Med/Surg \| $3,262 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
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$134,759	25	Provisions the same as Inpatient	$2,979 Med/Surg \| $3,262 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
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceQUALITY	$219,870	40	Provisions the same as Inpatient	$2,979 Med/Surg \| $3,262 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
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Adult	Programs of Excellence	PerformanceQUALITY	$252,496	45	Provisions the same as Inpatient	$2,979 Med/Surg \| $3,262 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
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$272,356	25		$2,979 Med/Surg \| $3,262 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 and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Heart/Lung	Heart/Lung	Adult	Member's Choice		$340,445	25		$2,979 Med/Surg \| $3,262 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 and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor: $102,133 \| Living Donor: $102,133	10 8		$2,979 Med/Surg \| $3,262 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 and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		$266,682	20		$2,979 Med/Surg \| $3,262 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 and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$146,107	15		$2,979 Med/Surg \| $3,262 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 and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	Cadaeric Donor: $202,848 \| Living Donor: $219,870	15		$2,979 Med/Surg \| $3,262 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 and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Lung	Lung	Adult	Member's Choice		Single: $266,682 \| Bilateral: $340,445	20		$2,979 Med/Surg \| $3,262 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 and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Pancreas	Pancreas	Adult	Member's Choice		$99,296	10		$2,979 Med/Surg \| $3,262 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 and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$170,222	30		$2,979 Med/Surg \| $3,262 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
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$187,352	35		$2,979 Med/Surg \| $3,262 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
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$134,759	25		$2,979 Med/Surg \| $3,262 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
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Pediatric	Programs of Excellence		$219,870	40		$2,979 Med/Surg \| $3,262 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
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Pediatric	Programs of Excellence		$252,496	45		$2,979 Med/Surg \| $3,262 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
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Heart	Heart	Pediatric	Member's Choice		$272,356	25		$2,979 Med/Surg \| $3,262 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 and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Heart/Lung	Heart/Lung	Pediatric	Member's Choice		$340,445	25		$2,979 Med/Surg \| $3,262 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 and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Kidney	Kidney	Pediatric	Member's Choice		Cadaveric Donor: $102,133 \| Living Donor: $102,133	10 \| 8		$2,979 Med/Surg \| $3,262 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 and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Kidney/Liver	Kidney/Liver	Pediatric	Member's Choice		$266,682	20		$2,979 Med/Surg \| $3,262 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 and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Kidney/Pancreas	Kidney/Pancreas	Pediatric	Member's Choice		$146,107	15		$2,979 Med/Surg \| $3,262 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 and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Liver	Liver	Pediatric	Member's Choice		Cadaveric Donor: $202,848 \| Living Donor: $219,870	15		$2,979 Med/Surg \| $3,262 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 and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Lung	Lung	Pediatric	Member's Choice		Single: $266,682 \| Bilateral: $340,445	20		$2,979 Med/Surg \| $3,262 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 and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
Florida Hospital Medical Center	Transplant	Daytona Beach	FL	Pancreas	Pancreas	Pediatric	Member's Choice		$99,296	10		$2,979 Med/Surg \| $3,262 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 and Ends when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Heart	Heart	Adult	Member's Choice		Hospital: $246,946 \| Professional: $77,391	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 for up to 17 (adult) or 35 (pediatric) Consecutive Inpatient Days, and if Applicable, any Outlier Days, Ending the Day of Discharge	Ends One (1) Year from Discharge
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 Ending the Day of Discharge	Ends One (1) Year from Discharge
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $161,817 \| Professional: $31,238 \| Professional (Living Donor): $11,609	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 Ending the Day of Discharge	Ends One (1) Year from Discharge
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $205,345 \| 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 Ending the Day of Discharge	Ends One (1) Year from Discharge
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	Hospital Cadaveric Donor: $247,918 \| Hospital Living Donor: $261,319 \| Professional Cadaveric or Living Donor: $69,933 \| 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 Ending the Day of Discharge	Ends One (1) Year from Discharge
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Lung	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			65% of Billed Charges	65% of Billed Charges	N/A	Begins at Evaluation	Beginning One (1) Day Prior to Transplant and Ending the Day of Discharge	Ends One (1) Year from Discharge
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 Ending the Day of Discharge	Ends One (1) Year from Discharge
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Heart	Heart	Pediatric	Member's Choice		Hospital: $260,314 \| 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 for up to 17 (adult) or 35 (pediatric) consecutive Inpatient Days, and if Applicable, any Outlier Days, Ending the Day of Discharge	Ends One (1) Year from Discharge
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 Ending the Day of Discharge	Ends One (1) Year from Discharge
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Kidney	Kidney	Pediatric	Programs of Excellence		Hospital: $161,817 \| Professional: $35,178 \| Professional (Living Donor): $11,609	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 Ending the Day of Discharge	Ends One (1) Year from Discharge
Jackson Memorial Hospital University of Miami School of Medicine	Transplant	Miami	FL	Liver	Liver	Pediatric	Programs of Excellence		Hospital Cadaveric Donor: $247,918 \| Hospital Living Donor: $261,319 \| Professional Cadaveric or Living Donor: $69,933 \| 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 Ending the Day of Discharge	Ends One (1) Year from Discharge
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 Ending the Day of Discharge	Ends One (1) Year from Discharge
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 Ending the Day of Discharge	Ends One (1) Year from Discharge
Mayo Clinic Florida	Transplant	Jacksonville	FL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		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
Mayo Clinic Florida	Transplant	Jacksonville	FL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$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
Mayo Clinic Florida	Transplant	Jacksonville	FL	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$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
Mayo Clinic Florida	Transplant	Jacksonville	FL	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$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
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
Mayo Clinic Florida	Transplant	Jacksonville	FL	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	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
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
Mayo Clinic Florida	Transplant	Jacksonville	FL	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	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
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
Mayo Clinic Florida	Transplant	Jacksonville	FL	Pancreas	Pancreas	Adult	Member's Choice		$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
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 from Discharge
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 from Discharge
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 from Discharge
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 from Discharge
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 from Discharge
Moffitt Cancer Center	Transplant	Tampa	FL	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceELITE	1st Infusion: $75,000 \| 2nd Infusion: $50,000	1st Infusion: 120 \| 2nd Infusion: 50		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 from Discharge
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 Discharge
Tampa General Hospital	Transplant	Tampa	FL	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	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 Discharge
Tampa General Hospital	Transplant	Tampa	FL	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceELITE	$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 Discharge
Tampa General Hospital	Transplant	Tampa	FL	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	$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 Discharge
Tampa General Hospital	Transplant	Tampa	FL	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	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 Discharge
UF Health Shands Hospital	Transplant	Gainesville	FL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$215,428	N/A		N/A	90% of Billed Charges	80% of Billed Charges	75% of Billed Charges	100% of Billed Charges			Charges in Excess of $343,403 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
UF Health Shands Hospital	Transplant	Gainesville	FL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$247,419	N/A		N/A	90% of Billed Charges	80% of Billed Charges	75% of Billed Charges	100% of Billed Charges			Charges in Excess of $418,056 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
UF Health Shands Hospital	Transplant	Gainesville	FL	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		Breast Cancer: $149,305 \| Non-Breast Cancer: $181,659	N/A		N/A	90% of Billed Charges	80% of Billed Charges	75% of Billed Charges	100% of Billed Charges			Charges in Excess of $275,147 (Breast Cancer) or $324,203 (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
UF Health Shands Hospital	Transplant	Gainesville	FL	Heart	Heart	Adult	Member's Choice		$279,415	N/A		N/A	90% of Billed Charges	80% of Billed Charges			100% of Billed Charges	80% of Billed Charges	Charges in Excess of $439,385 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
UF Health Shands Hospital	Transplant	Gainesville	FL	Kidney	Kidney	Adult	Member's Choice		Cadaveric Donor: $89,581 \| Living Donor: $81,052	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 $157,835 (Cadaveric) or $147,174 (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
UF Health Shands Hospital	Transplant	Gainesville	FL	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	$155,704	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 $268,747, 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
UF Health Shands Hospital	Transplant	Gainesville	FL	Liver	Liver	Adult	Member's Choice		Cadaveric Donor: $230,358 \| Living Donor: $211,159	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 $377,531 (Cadaveric) or $358,333 (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
UF Health Shands Hospital	Transplant	Gainesville	FL	Lung	Lung	Adult	Programs of Excellence	PerformanceELITE	Single: $181,297 \| Bilateral: $188,802	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 $319,940 (Single Lung) or $371,128 (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
UF Health Shands Hospital	Transplant	Gainesville	FL	Liver	Liver	Pediatric	Member's Choice		$277,280	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 $473,508 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
University of Miami Hospital & Clinics	Transplant	Miami	FL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	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
University of Miami Hospital & Clinics	Transplant	Miami	FL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	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
University of Miami Hospital & Clinics	Transplant	Miami	FL	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	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
University of Miami Hospital & Clinics	Transplant	Miami	FL	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceSELECT	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
University of Miami Hospital & Clinics	Transplant	Miami	FL	Blood/Marrow (Tandem Auto to Related Allo)	Tandem Auto to Allo	Adult	Programs of Excellence	PerformanceSELECT	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
University of Miami Hospital & Clinics	Transplant	Miami	FL	Blood/Marrow (Tandem Auto to Unrelated Allo)	Tandem Auto to Allo	Adult	Programs of Excellence	PerformanceSELECT	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
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
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
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
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
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
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$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
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$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
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$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
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
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	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
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	$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
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
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
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$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
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$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
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$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
University of Iowa Hospitals and Clinics	Transplant	Iowa City	IA	Heart	Heart	Pediatric	Programs of Excellence		$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
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
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
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
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
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
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
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
Advocate Christ Medical Center	Transplant	Oak Lawn	IL	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$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
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
Advocate Christ Medical Center	Transplant	Oak Lawn	IL	Lung	Lung	Adult	Member's Choice		Single: $195,000 \| Bilateral: $285,000	20		$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 $195,000 (Single) or $570,000 (Bilateral), 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
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	Included in Case Rate	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
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	Included in Case Rate	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
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	Included in Case Rate	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
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	Included in Case Rate	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
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	Included in Case Rate	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
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 from Discharge
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	Invoice Cost	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends when Inlier Days have Expired	Ends One (1) Year from Discharge
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	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
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	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
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
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
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
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
Northwestern Memorial Hospital	Transplant	Chicago	IL	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$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
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
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
Northwestern Memorial Hospital	Transplant	Chicago	IL	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	$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
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
Northwestern Memorial Hospital	Transplant	Chicago	IL	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	$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
University of Chicago Medical Center	Transplant	Chicago	IL	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$1338,00	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
University of Chicago Medical Center	Transplant	Chicago	IL	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$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
University of Chicago Medical Center	Transplant	Chicago	IL	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$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
University of Chicago Medical Center	Transplant	Chicago	IL	Heart	Heart	Adult	Programs of Excellence	PerformanceELITE	$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
University of Chicago Medical Center	Transplant	Chicago	IL	Kidney	Kidney	Adult	Member's Choice		$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
University of Chicago Medical Center	Transplant	Chicago	IL	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$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
University of Chicago Medical Center	Transplant	Chicago	IL	Liver	Liver	Adult	Member's Choice		$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
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
University of Chicago Medical Center	Transplant	Chicago	IL	Pancreas	Pancreas	Adult	Member's Choice		$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
Indiana Blood and 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
Indiana Blood and 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
Indiana Blood and 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
IUH - Indiana University Medical Center	Transplant	Indianapolis	IN	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$165,000	35		$3,848 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 ($450,000) 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
IUH - Indiana University Medical Center	Transplant	Indianapolis	IN	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$215,000	40		$3,848 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 ($490,000) 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
IUH - Indiana University Medical Center	Transplant	Indianapolis	IN	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$127,000	20		$3,848 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 ($254,000) 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
IUH - Indiana University Medical Center	Transplant	Indianapolis	IN	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Member's Choice		1st: $122,000 \| 2nd: $100,000	20 \| 20		$3,848 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: $244,000; 2nd: $200,000) 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
IUH - Indiana University Medical Center	Transplant	Indianapolis	IN	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$98,000	12		$3,848 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 ($196,000) 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
IUH - Indiana University Medical Center	Transplant	Indianapolis	IN	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		$325,000	25		$3,848 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 ($750,000) 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
IUH - Indiana University Medical Center	Transplant	Indianapolis	IN	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceELITE	$182,000	15		$3,848 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 ($364,000) 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
IUH - Indiana University Medical Center	Transplant	Indianapolis	IN	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	$225,000	23		$3,848 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 ($450,000) 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
IUH - Indiana University Medical Center	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
IUH - Indiana University Medical Center	Transplant	Indianapolis	IN	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$222,000	22		$3,848 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 ($540,000) 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
IUH - Indiana University Medical Center	Transplant	Indianapolis	IN	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	Single: $145,000 \| Bilateral: $220,000	20 \| 25		$3,848 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: $420,000; Double: $514,000) 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
IUH - Indiana University Medical Center	Transplant	Indianapolis	IN	Multi-Visceral	Multi-Visceral	Adult	Member's Choice		70% of Billed Charges	N/A		N/A	N/A	Pre: 70% of Billed Charges \| Post: 80% of Billed Charges			70% of Billed Charges	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
IUH - Riley Hospital for Children	Transplant	Indianapolis	IN	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$180,000	35		$3,848 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 ($475,000) 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
IUH - Riley Hospital for Children	Transplant	Indianapolis	IN	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$250,000	40		$3,848 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 ($526,000) 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
IUH - Riley Hospital for Children	Transplant	Indianapolis	IN	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$166,000	20		$3,848 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 ($332,000) 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
IUH - Riley Hospital for Children	Transplant	Indianapolis	IN	Heart	Heart	Pediatric	Member's Choice		$235,000	22		$3,848 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 ($580,000) 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
IUH - Riley Hospital for Children	Transplant	Indianapolis	IN	Kidney	Kidney	Pediatric	Programs of Excellence		$111,000	12		$3,848 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 ($222,000) 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
IUH - Riley Hospital for Children	Transplant	Indianapolis	IN	Liver	Liver	Pediatric	Programs of Excellence		$286,000	23		$3,848 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 ($286,000) 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
IUH - 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
Jewish Hospital	Transplant	Louisville	KY	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $72,000 \| Physicians Group: 80% of Billed Charges \| Anesthesia Physicians: 70% of Billed Charges	10		Hospital: $2,100 Med/Surg; $3,000 ICU/CCU \| Physicians: Same as Case Rate	Hospital: 75% of Billed Charges \| Physicians: Same as Case Rate	Hospital: 70% of Billed Charges \| Physicians: Same as Case Rate			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
Jewish Hospital	Transplant	Louisville	KY	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		Hospital: $62,000 \| Physicians Group: 80% of Billed Charges \| Anesthesia Physicians: 70% of Billed Charges	10		Hospital: $2,100 Med/Surg; $3,000 ICU/CCU \| Physicians: Same as Case Rate	Hospital: 75% of Billed Charges \| Physicians: Same as Case Rate	Hospital: 70% of Billed Charges \| Physicians: Same as Case Rate			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
Jewish Hospital	Transplant	Louisville	KY	Liver	Liver	Adult	Member's Choice		Hospital (Cadaveric Donor): $138,000 \| Hospital (Living Donor): $148,000 \| Physicians Group: 80% of Billed Charges\| Anesthesia Physicians: 70% of Billed Charges	18		Hospital: $2,100 Med/Surg; $3,000 ICU/CCU \| Physicians: Same as Case Rate	Hospital: 75% of Billed Charges \| Physicians: Same as Case Rate	Hospital: 70% of Billed Charges \| Physicians: Same as Case Rate			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
Jewish Hospital	Transplant	Louisville	KY	Lung	Lung	Adult	Member's Choice		Hospital (Single Lung): $126,000 \| Hospital (Bilateral Lung): $136,000 \| Physicians Group: 80% of Billed Charges \| Anesthesia Physicians: 70% of Billed Charges	21		Hospital: $2,100 Med/Surg; $3,000 ICU/CCU \| Physicians: Same as Case Rate	Hospital: 75% of Billed Charges \| Physicians: Same as Case Rate	Hospital: 70% of Billed Charges \| Physicians: Same as Case Rate			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
University of Kentucky Medical Center	Transplant	Lexington	KY	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$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
University of Kentucky Medical Center	Transplant	Lexington	KY	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$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
University of Kentucky Medical Center	Transplant	Lexington	KY	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$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
University of Kentucky Medical Center	Transplant	Lexington	KY	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$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
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
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
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
University of Kentucky Medical Center	Transplant	Lexington	KY	Lung	Lung	Adult	Member's Choice		Single: $175,049 \| Bilateral: $196,267	20 \| 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
University of Kentucky Medical Center	Transplant	Lexington	KY	Pancreas	Pancreas	Adult	Member's Choice		$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
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 1.5 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
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 1.5 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
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 1.5 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
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 1.5 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
Ochsner Foundation Hospital	Transplant	Jefferson	LA	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$187,079	N/A		N/A	80% of Billed Charges	80% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed $299,327, 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
Ochsner Foundation Hospital	Transplant	Jefferson	LA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$88,242	N/A		N/A	80% of Billed Charges	80% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed $141,187, 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
Ochsner Foundation Hospital	Transplant	Jefferson	LA	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		$266,630	N/A		N/A	80% of Billed Charges	80% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed $426,608, 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
Ochsner Foundation Hospital	Transplant	Jefferson	LA	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceELITE	$146,012	N/A		N/A	80% of Billed Charges	80% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed $233,619, 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
Ochsner Foundation Hospital	Transplant	Jefferson	LA	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	$221,911	N/A		N/A	80% of Billed Charges	80% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed 355,05800, 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
Ochsner Foundation Hospital	Transplant	Jefferson	LA	Lung	Lung	Adult	Member's Choice		$210,675	N/A		N/A	80% of Billed Charges	80% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed 337,800, 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
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
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
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
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
Beth Israel DeacOness Medical Center	Transplant	Boston	MA	Kidney	Kidney	Adult	Member's Choice		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
Beth Israel DeacOness Medical Center	Transplant	Boston	MA	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		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
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
Beth Israel DeacOness Medical Center	Transplant	Boston	MA	Pancreas	Pancreas	Adult	Member's Choice		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
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
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
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
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
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
Boston Children's Hospital	Transplant	Boston	MA	Liver	Liver	Pediatric	Member's Choice		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
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
Brigham and Women's Hospital	Transplant	Boston	MA	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $155,000 \| Professional: 80% of Billed Charges	22		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
Brigham and Women's Hospital	Transplant	Boston	MA	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	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
Brigham and Women's Hospital	Transplant	Boston	MA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	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
Brigham and Women's Hospital	Transplant	Boston	MA	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	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
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
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
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
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
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
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
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
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
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
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
Massachusetts General Hospital	Transplant	Boston	MA	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	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
Massachusetts General Hospital	Transplant	Boston	MA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	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
Massachusetts General Hospital	Transplant	Boston	MA	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	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
Massachusetts General Hospital	Transplant	Boston	MA	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	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
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
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
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
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
Tufts Medical Center	Transplant	Boston	MA	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$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
Tufts Medical Center	Transplant	Boston	MA	Kidney	Kidney	Adult	Member's Choice		$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
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
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
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
Johns Hopkins Hospital	Transplant	Baltimore	MD	Heart	Heart	Adult	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
Johns Hopkins Hospital	Transplant	Baltimore	MD	Kidney	Kidney	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
Johns Hopkins Hospital	Transplant	Baltimore	MD	Kidney/Pancreas	Kidney/Pancreas	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
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
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
Johns Hopkins Hospital	Transplant	Baltimore	MD	Pancreas	Pancreas	Adult	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
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
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
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
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
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
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
University of Maryland Medical System	Transplant	Baltimore	MD	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$149,051	35		$3,943 Med/Surg \| $4,542 ICU/CCU	N/A	Hospital: 100% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 90 Days Post-Transplant Discharge
University of Maryland Medical System	Transplant	Baltimore	MD	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$198,735	35		$3,943 Med/Surg \| $4,542 ICU/CCU	N/A	Hospital: 100% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 90 Days Post-Transplant Discharge
University of Maryland Medical System	Transplant	Baltimore	MD	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$110,408	25		$3,943 Med/Surg \| $4,542 ICU/CCU	N/A	Hospital: 100% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate	Included in Case Rate			N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 90 Days Post-Transplant Discharge
University of Maryland Medical System	Transplant	Baltimore	MD	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$214,414	18		$3,943 Med/Surg \| $4,542 ICU/CCU	N/A	Hospital: 100% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	Reimbursed at HSCRC Rate	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 90 Days Post-Transplant Discharge
University of Maryland Medical System	Transplant	Baltimore	MD	Kidney	Kidney	Adult	Member's Choice		Cadaveric Donor: $121,233 \| Living Donor: $127,777	8		$3,943 Med/Surg \| $4,542 ICU/CCU	N/A	Hospital: 100% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	Reimbursed at HSCRC Rate	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 90 Days Post-Transplant Discharge
University of Maryland Medical System	Transplant	Baltimore	MD	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceELITE	$224,128	14		$3,943 Med/Surg \| $4,542 ICU/CCU	N/A	Hospital: 100% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	Reimbursed at HSCRC Rate	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 90 Days Post-Transplant Discharge
University of Maryland Medical System	Transplant	Baltimore	MD	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor w/o Renal Failure: $232,654 \| Cadaveric Donor with Renal Failure: $311,201 \| Living Donor: $222,708	18		$3,943 Med/Surg \| $4,542 ICU/CCU	N/A	Hospital: 100% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	Reimbursed at HSCRC Rate	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 90 Days Post-Transplant Discharge
University of Maryland Medical System	Transplant	Baltimore	MD	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	Single: $205,557 \| Bilateral: $278,456	18 \| 20		$3,943 Med/Surg \| $4,542 ICU/CCU	N/A	Hospital: 100% of Billed Charges \| Professional: 75% of Billed Charges			Included in Case Rate	Reimbursed at HSCRC Rate	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplantation and Ends when Inlier and any Applicable Outlier Days have Expired	Ends 90 Days Post-Transplant Discharge
Henry Ford Hospital	Transplant	Detroit	MI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$134,900	35		$3,000 Med/Surg \| $3,500 ICU/CCU	85% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			Billed Charges Exceed $269,800 Payment will be the Transplant Case Rate, Plus 45% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge
Henry Ford Hospital	Transplant	Detroit	MI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$175,000	40		$3,000 Med/Surg \| $3,500 ICU/CCU	85% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			Billed Charges Exceed $350,000 Payment will be the Transplant Case Rate, Plus 45% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge
Henry Ford Hospital	Transplant	Detroit	MI	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$84,900	30		$3,000 Med/Surg \| $3,500 ICU/CCU	85% of Billed Charges	70% of Billed Charges	Included in Case Rate	Included in Case Rate			Billed Charges Exceed $169,800 Payment will be the Transplant Case Rate, Plus 45% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge
Henry Ford Hospital	Transplant	Detroit	MI	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$145,000	18		$3,000 Med/Surg \| $3,500 ICU/CCU	85% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost, Plus 10%	Billed Charges Exceed $290,000 Payment will be the Transplant Case Rate, Plus 45% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge
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 Invoice Cost, Plus 10%	N/A	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge
Henry Ford Hospital	Transplant	Detroit	MI	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	$69,900	12		$3,000 Med/Surg \| $3,500 ICU/CCU	85% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost, Plus 10%	Billed Charges Exceed $139,800 Payment will be the Transplant Case Rate, Plus 45% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge
Henry Ford Hospital	Transplant	Detroit	MI	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$124,850	15		$3,000 Med/Surg \| $3,500 ICU/CCU	85% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost, Plus 10%	Billed Charges Exceed $249,700 Payment will be the Transplant Case Rate, Plus 45% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge
Henry Ford Hospital	Transplant	Detroit	MI	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	$159,900	17		$3,000 Med/Surg \| $3,500 ICU/CCU	85% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost, Plus 10%	Billed Charges Exceed $319,8000 Payment will be the Transplant Case Rate, Plus 45% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge
Henry Ford Hospital	Transplant	Detroit	MI	Lung	Lung	Adult	Member's Choice		$145,000	25		$3,000 Med/Surg \| $3,500 ICU/CCU	85% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost, Plus 10%	If Billed Charges Exceed $290,000, Payment will be the Transplant Case Rate, Plus 45% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 365 Days from Discharge
Henry Ford Hospital	Transplant	Detroit	MI	Pancreas	Pancreas	Adult	Member's Choice		$89,900	15		$3,000 Med/Surg \| $3,500 ICU/CCU	85% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost, Plus 10%	If Billed Charges Exceed $179,800, Payment will be the Transplant Case Rate, Plus 45% of the Excess Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge
Karmanos Cancer Institute	Transplant	Detroit	MI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$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
Karmanos Cancer Institute	Transplant	Detroit	MI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$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
Karmanos Cancer Institute	Transplant	Detroit	MI	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$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
Spectrum Health	Transplant	Grand Rapids	MI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$162,365	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
Spectrum Health	Transplant	Grand Rapids	MI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$189,426	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
Spectrum Health	Transplant	Grand Rapids	MI	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$108,243	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
Spectrum Health	Transplant	Grand Rapids	MI	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$303,081	28		N/A	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
Spectrum Health	Transplant	Grand Rapids	MI	Lung	Lung	Adult	Programs of Excellence	PerformanceELITE	$243,547	30		N/A	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
Spectrum Health	Transplant	Grand Rapids	MI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$331,224	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
Spectrum Health	Transplant	Grand Rapids	MI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$331,224	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
Spectrum Health	Transplant	Grand Rapids	MI	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$141,040	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
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
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
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
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$166,000	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
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$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
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	$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
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	$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
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	Single $150,100 \| 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
University of Michigan Medical Center	Transplant	Ann Arbor	MI	Pancreas	Pancreas	Adult	Member's Choice		$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
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
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
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
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
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
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
Rochester Methodist Hospital (Mayo Clinic)	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
Rochester Methodist Hospital (Mayo Clinic)	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
Rochester Methodist Hospital (Mayo Clinic)	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
Rochester Methodist Hospital (Mayo Clinic)	Transplant	Rochester	MN	Heart	Heart	Adult	Member's Choice		$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
Rochester Methodist Hospital (Mayo Clinic)	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
Rochester Methodist Hospital (Mayo Clinic)	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
Rochester Methodist Hospital (Mayo Clinic)	Transplant	Rochester	MN	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	$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
Rochester Methodist Hospital (Mayo Clinic)	Transplant	Rochester	MN	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	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
Rochester Methodist Hospital (Mayo Clinic)	Transplant	Rochester	MN	Lung	Lung	Adult	Member's Choice		$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
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$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
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$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
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Blood/Marrow (Cord Blood)	Cord Blood	Adult	Member's Choice		$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
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$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
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	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
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
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
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
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
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
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
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
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
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	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
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	$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
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor Meld Score < 20: $145,000 \| 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
University of Minnesota Medical Center, Fairview	Transplant	Minneapolis	MN	Lung	Lung	Adult	Member's Choice		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
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
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
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
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
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
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
Barnes-Jewish Hospital	Transplant	St Louis	MO	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		Hospital: $182,913 \| Professional: $31,978	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
Barnes-Jewish Hospital	Transplant	St Louis	MO	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		Hospital: $241,544 \| Professional: $42,220	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
Barnes-Jewish Hospital	Transplant	St Louis	MO	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		Hospital: $124,895 \| Professional: $21,835	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
Barnes-Jewish Hospital	Transplant	St Louis	MO	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $239,820 \| Professional: $54,563	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 on the Day of Ablative Therapy and Ends at the Earlier of Discharge or Transfer to Inpatient rehabilitation	Ends One (1) Year from Discharge
Barnes-Jewish Hospital	Transplant	St Louis	MO	Heart/Lung	Heart/Lung	Adult	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
Barnes-Jewish Hospital	Transplant	St Louis	MO	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor Hospital: $99,568 \| Cadaveric Donor Professional: $18,695 \| Living Donor Hospital: $107,761 \| Living Donor Professional: $28,345	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 and Ends at the Earlier of Discharge or Transfer to Inpatient Rehabilitation Unit or Facility	Ends 365 Days from Discharge
Barnes-Jewish Hospital	Transplant	St Louis	MO	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	N/A	N/A		N/A	N/A	N/A			N/A	N/A	N/A	N/A	N/A	N/A
Barnes-Jewish Hospital	Transplant	St Louis	MO	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor Hospital: $196,705 \| Cadaveric Donor Professional: $47,684 \| Living Donor Hospital: $223,985 \| Living Donor Professional: $48,051	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 and Ends at the Earlier of Discharge or Transfer to Inpatient Rehabilitation Unit or Facility	Ends 365 Days from Discharge
Barnes-Jewish Hospital	Transplant	St Louis	MO	Lung	Lung	Adult	Programs of Excellence	PerformanceELITE	Single Lung Hospital: $201,450 \| Single Lung Professional: $47,893 \| Bilateral Lung Hospital: $247,421 \| Bilateral Lung Professional: $53,724	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 and Ends at the Earlier of Discharge or Transfer to Inpatient Rehabilitation Unit or Facility	Ends 365 Days from Discharge
Barnes-Jewish Hospital	Transplant	St Louis	MO	Pancreas	Pancreas	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 and Ends at the Earlier of Discharge or Transfer to Inpatient Rehabilitation Unit or Facility	Ends 365 Days from Discharge
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
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
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
SSM Health Saint Louis University Hospital	Transplant	St Louis	MO	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$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
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
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
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
SSM Health Saint Louis University Hospital	Transplant	St Louis	MO	Pancreas	Pancreas	Adult	Member's Choice		$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
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
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
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
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
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
St Louis Children's Hospital	Transplant	St Louis	MO	Kidney	Kidney	Pediatric	Member's Choice		$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
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
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
University of Mississippi Medical Center	Transplant	Jackson	MS	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$141,000	30		$2,850 Med/Surg \| $3,850 ICU/CCU	100% of Billed Charges	80% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			If Billed Charges Exceed $246,750, 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 when Inlier and any Applicable Outlier Days have Expired	Ends 365 Days from Discharge
University of Mississippi Medical Center	Transplant	Jackson	MS	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$160,000	35		$2,850 Med/Surg \| $3,850 ICU/CCU	100% of Billed Charges	80% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			If Billed Charges Exceed $280,000, 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 any Applicable Outlier Days have Expired	Ends 365 Days from Discharge
University of Mississippi Medical Center	Transplant	Jackson	MS	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$96,000	25		$2,850 Med/Surg \| $3,850 ICU/CCU	100% of Billed Charges	80% of Billed Charges	Included in Case Rate	Reimbursed at Invoice Cost			If Billed Charges Exceed $168,000, 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 any Applicable Outlier Days have Expired	Ends 365 Days from Discharge
University of Mississippi Medical Center	Transplant	Jackson	MS	Heart	Heart	Adult	Member's Choice		$172,000	28		$2,850 Med/Surg \| $3,850 ICU/CCU	100% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost + 15%	IF Billed Charges Exceed $301,000, 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 365 Days from Discharge
University of Mississippi Medical Center	Transplant	Jackson	MS	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$75,000	8		$2,850 Med/Surg \| $3,850 ICU/CCU	100% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost + 15%	If Billed Charges Exceed $131,250, 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 365 Days from Discharge
University of Mississippi Medical Center	Transplant	Jackson	MS	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$130,000	18		$2,850 Med/Surg \| $3,850 ICU/CCU	100% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost + 15%	If Billed Charges Exceed $227,500, 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 365 Days from Discharge
University of Mississippi Medical Center	Transplant	Jackson	MS	Liver	Liver	Adult	Member's Choice		$148,000	14		$2,850 Med/Surg \| $3,850 ICU/CCU	100% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost + 15%	If Billed Charges Exceed $259,000, 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 365 Days from Discharge
University of Mississippi Medical Center	Transplant	Jackson	MS	Pancreas	Pancreas	Adult	Member's Choice		$93,000	12		$2,850 Med/Surg \| $3,850 ICU/CCU	100% of Billed Charges	80% of Billed Charges			Included in Case Rate	Invoice Cost + 15%	If Billed Charges Exceed $162,750, 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 365 Days from Discharge
Duke University Hospital	Transplant	Durham	NC	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$200,000	N/A		N/A	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
Duke University Hospital	Transplant	Durham	NC	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$248,000	N/A		N/A	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
Duke University Hospital	Transplant	Durham	NC	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$100,000	N/A		N/A	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
Duke University Hospital	Transplant	Durham	NC	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$220,000	N/A		N/A	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
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	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
Duke University Hospital	Transplant	Durham	NC	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	$155,000	N/A		N/A	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
Duke University Hospital	Transplant	Durham	NC	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor: $180,000 \| Living Donor: $190,000	N/A		N/A	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
Duke University Hospital	Transplant	Durham	NC	Lung	Lung	Pediatric	Programs of Excellence		Single: $260,000 \| Bilateral: $270,000	N/A		N/A	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
Duke University Hospital	Transplant	Durham	NC	Lung	Lung	Adult	Programs of Excellence	PerformanceELITE	Single: $250,000 \| Bilateral: $265,000	N/A		N/A	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
Duke University Hospital	Transplant	Durham	NC	Heart	Heart	Pediatric	Programs of Excellence		$240,000	N/A		N/A	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
Duke University Hospital	Transplant	Durham	NC	Kidney	Kidney	Pediatric	Member's Choice		Cadaveric Donor: $98,000 \| Living Donor: $105,000	N/A		N/A	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
Duke University Hospital	Transplant	Durham	NC	Liver	Liver	Pediatric	Programs of Excellence		Cadaveric Donor: $180,000 \| Living Donor: $190,000	N/A		N/A	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
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	$164,617	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 $329,234, 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
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	$202,873	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 $405,746, 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
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	$110,131	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 $220,262, 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
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$173,891	N/A		N/A	100% of Billed Charges	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed $347,782, 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 One (1) Year from Discharge
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$93,901	N/A		N/A	100% of Billed Charges	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed $187,802, 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 One (1) Year from Discharge
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	$162,298	N/A		N/A	100% of Billed Charges	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed $324,596, 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 One (1) Year from Discharge
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	$162,298	N/A		N/A	100% of Billed Charges	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed $324,596, 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 One (1) Year from Discharge
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Pancreas	Pancreas	Adult	Member's Choice		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 One (1) Year from Discharge
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$164,617	N/A		N/A	100% of Billed Charges	65% of Billed Charges	Included in Case Rate	65% of Billed Charges			If Billed Charges Exceed $329,234, 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 One (1) Year from Discharge
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$202,873	N/A		N/A	100% of Billed Charges	65% of Billed Charges	Included in Case Rate	65% of Billed Charges			If Billed Charges Exceed $405,746, 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 One (1) Year from Discharge
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$110,131	N/A		N/A	100% of Billed Charges	65% of Billed Charges	Included in Case Rate	N/A			If Billed Charges Exceed $220,262, 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
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Heart	Heart	Pediatric	Member's Choice		$173,891	N/A		N/A	100% of Billed Charges	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed $347,782, 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 One (1) Year from Discharge
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Kidney	Kidney	Pediatric	Programs of Excellence		$93,901	N/A		N/A	100% of Billed Charges	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed $187,802, 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 One (1) Year from Discharge
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 One (1) Year from Discharge
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Lung	Lung	Pediatric	Member's Choice		$162,298	N/A		N/A	100% of Billed Charges	65% of Billed Charges			Included in Case Rate	75% of Billed Charges	If Billed Charges Exceed $324,596, 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 One (1) Year from Discharge
University of North Carolina Hospitals	Transplant	Chapel Hill	NC	Pancreas	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 One (1) Year from Discharge
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
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): $116,000 \| 1st: $110,000; 2nd (Unrelated): $148,000	20, 30 \| 20, 32		$2,000 Med/Surg \| $2,775 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 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 Day 101 Post Inlier Days Period
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 \| $2,775 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 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 Day 101 Post Inlier Days Period
The Nebraska Medical Center	Transplant	Omaha	NE	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$145,000	30		$2,000 Med/Surg \| $2,775 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 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 Day 101 Post Inlier Days Period
The Nebraska Medical Center	Transplant	Omaha	NE	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$185,000	32		$2,000 Med/Surg \| $2,775 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 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	One (1) Year from Day 31 Post Inlier Days Period
The Nebraska Medical Center	Transplant	Omaha	NE	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$110,000	20		$1,600 Med/Surg \| $2,675 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 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	One (1) Year from Day 31 Post Inlier Days Period
The Nebraska Medical Center	Transplant	Omaha	NE	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$180,000	18		$2,000 Med/Surg \| $2,600 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 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 at Discharge	Ends One (1) Year from Day 91 Post Discharge
The Nebraska Medical Center	Transplant	Omaha	NE	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	$67,500	12 Patient \| 7 Donor		$2,000 Med/Surg \| $2,600 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 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 at Discharge	Ends One (1) Year from Day 91 Post Discharge
The Nebraska Medical Center	Transplant	Omaha	NE	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	$127,000	19		$2,000 Med/Surg \| $2,600 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 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 at Discharge	Ends One (1) Year from Day 91 Post Discharge
The Nebraska Medical Center	Transplant	Omaha	NE	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	$160,000	20 Patient \| 7 Donor		$2,000 Med/Surg \| $2,600 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 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 at Discharge	Ends One (1) Year from Day 91 Post Discharge
The Nebraska Medical Center	Transplant	Omaha	NE	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$145,000	30		$2,000 Med/Surg \| $2,775 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 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 Day 101 Post Discharge
The Nebraska Medical Center	Transplant	Omaha	NE	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$185,000	32		$2,000 Med/Surg \| $2,775 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 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 Day 101 Post Discharge
The Nebraska Medical Center	Transplant	Omaha	NE	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$110,000	20		$1,600 Med/Surg \| $2,675 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 75% of Billed Charges	Included in Case Rate	N/A			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 Day 31 Post Discharge
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	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
The Nebraska Medical Center	Transplant	Omaha	NE	Kidney	Kidney	Pediatric	Member's Choice		$72,000	12 Patient \| 7 Donor		$2,000 Med/Surg \| $2,600 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 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 at Discharge	Ends One (1) Year from Day 91 Post Discharge
The Nebraska Medical Center	Transplant	Omaha	NE	Liver	Liver	Pediatric	Programs of Excellence		$175,000	25 Patient \| 7 Donor		$2,000 Med/Surg \| $2,600 ICU/CCU	90% of Billed Charges	Hospital: 65% of Billed Charges \| Professional: 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 at Discharge	Ends One (1) Year from Day 91 Post Discharge
University of New Mexico Hospital	Transplant	Albuquerque	NM	Kidney	Kidney	Adult	Member's Choice		$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
Memorial Sloan-Kettering Cancer Center	Transplant	New York	NY	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceELITE	$286,379	50	Same Rate but 20 Days from Infusion Date	Hospital: $5,588 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 $4,556 or for an Inpatient Stay that Includes Surgery, a Per Diem Rate of $6,817 \| 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
Memorial Sloan-Kettering Cancer Center	Transplant	New York	NY	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceELITE	$286,379	50	Same Rate but 20 Days from Infusion Date	Hospital: $5,588 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 $4,556 or for an Inpatient Stay that Includes Surgery, a Per Diem Rate of $6,817 \| 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
Memorial Sloan-Kettering Cancer Center	Transplant	New York	NY	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceELITE	$139,230	35	Same Rate but 20 Days from Infusion Date	Hospital: $5,588 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 $4,556 or for an Inpatient Stay that Includes Surgery, a Per Diem Rate of $6,817 \| 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
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: $5,588 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 $4,556 or for an Inpatient Stay that Includes Surgery, a Per Diem Rate of $6,817 \| 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
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: $5,588 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 $4,556 or for an Inpatient Stay that Includes Surgery, a Per Diem Rate of $6,817 \| 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
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: $5,588 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 $4,556 or for an Inpatient Stay that Includes Surgery, a Per Diem Rate of $6,817 \| 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
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
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
Mount Sinai Medical Center	Transplant	New York	NY	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence		$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
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
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
Mount Sinai Medical Center	Transplant	New York	NY	Kidney	Kidney	Adult	Member's Choice		$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
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
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
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
Mount Sinai Medical Center	Transplant	New York	NY	Multi-Visceral	Multi-Visceral	Adult	Member's Choice		100% of Higher Cost Organ Case Rate, Plus 65% of Lower Cost Organ Case Rate	Equal to Number of Days of Higher Cost Organ		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
Mount Sinai Medical Center	Transplant	New York	NY	Pancreas	Pancreas	Adult	Member's Choice		$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
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
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
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
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
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
Mount Sinai Medical Center	Transplant	New York	NY	Kidney	Kidney	Pediatric	Member's Choice		$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
Mount Sinai Medical Center	Transplant	New York	NY	Liver	Liver	Pediatric	Member's Choice		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
Mount Sinai Medical Center	Transplant	New York	NY	Multi-Visceral	Multi-Visceral	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
Strong Memorial Hospital, Rochester	Transplant	Rochester	NY	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$226,800	40		Days 41-60: $5,600 Med/Surg, $5,600 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
Strong Memorial Hospital, Rochester	Transplant	Rochester	NY	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$268,000	40		Days 41-60: $5,600 Med/Surg $5,600 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
Strong Memorial Hospital, Rochester	Transplant	Rochester	NY	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$159,500	25		Days 25-45: $5,600 Med/Surg $5,600 ICU/CCU \| Day 46-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
Strong Memorial Hospital, Rochester	Transplant	Rochester	NY	Heart	Heart	Adult	Member's Choice		$245,300	30		Days 21-40: $5,500 Med/Surg $5,500 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
Strong Memorial Hospital, Rochester	Transplant	Rochester	NY	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	$99,200	15		Days 16-35: $5,500 Med/Surg $5,500 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
Strong Memorial Hospital, Rochester	Transplant	Rochester	NY	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$178,700	20		Days 21-40: $5,500 Med/Surg $5,500 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
Strong Memorial Hospital, Rochester	Transplant	Rochester	NY	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor: $254,800 \| Living Donor: $265,800	25		Days 26-45: $5,500 Med/Surg $5,500 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
Strong Memorial Hospital, Rochester	Transplant	Rochester	NY	Pancreas	Pancreas	Adult	Member's Choice		$127,900	20		Days 21-40: $5,500 Med/Surg $5,500 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
Strong Memorial Hospital, Rochester	Transplant	Rochester	NY	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Member's Choice		$226,800	40		Days 41-60: $5,600 Med/Surg $5,600 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
Strong Memorial Hospital, Rochester	Transplant	Rochester	NY	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Member's Choice		$268,000	40		Days 41-60: $5,600 Med/Surg $5,600 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
Strong Memorial Hospital, Rochester	Transplant	Rochester	NY	Blood/Marrow (Autologous)	Autologous	Pediatric	Member's Choice		$159,500	25		Days 25-45: $5,600 Med/Surg $5,600 ICU/CCU \| Day 46-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
Strong Memorial Hospital, Rochester	Transplant	Rochester	NY	Heart	Heart	Pediatric	Member's Choice		$245,300	30		Days 21-40: $5,500 Med/Surg, $5,500 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
Strong Memorial Hospital, Rochester	Transplant	Rochester	NY	Kidney	Kidney	Pediatric	Member's Choice		$99,200	15		Days 16-35: $5,500 Med/Surg, $5,500 ICU/CCU \| Day 36-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
Strong Memorial Hospital, Rochester	Transplant	Rochester	NY	Kidney/Pancreas	Kidney/Pancreas	Pediatric	Member's Choice		$178,700	20		Days 21-40: $5,500 Med/Surg, $5,500 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
Strong Memorial Hospital, Rochester	Transplant	Rochester	NY	Liver	Liver	Pediatric	Member's Choice		Cadaveric Donor: $254,800 \| Living Donor: $265,800	25		Days 26-45: $5,500 Med/Surg, $5,500 ICU/CCU \| Day 46-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
Strong Memorial Hospital, Rochester	Transplant	Rochester	NY	Pancreas	Pancreas	Pediatric	Member's Choice		$127,900	20		Days 21-40: $5,500 Med/Surg, $5,500 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
Arthur G James Cancer Hospital	Transplant	Columbus	OH	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	$199,500	N/A		N/A	75% of Billed Charges	60% of Billed Charges	Included in Case Rate	Invoice Cost			If Billed Charges Exceed $472,500, 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 One (1) Year from Discharge
Arthur G James Cancer Hospital	Transplant	Columbus	OH	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	$236,250	N/A		N/A	75% of Billed Charges	60% of Billed Charges	Included in Case Rate	Invoice Cost			If Billed Charges Exceed $603,750, 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 One (1) Year from Discharge
Arthur G James Cancer Hospital	Transplant	Columbus	OH	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	$126,000	N/A		N/A	75% of Billed Charges	60% of Billed Charges	Included in Case Rate	Invoice Cost			If Billed Charges Exceed $341,250, 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 One (1) Year from Discharge
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
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
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
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
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
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
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
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
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
Cincinnati Children's Hospital Medical Center	Transplant	Cincinnati	OH	Liver	Liver	Pediatric	Programs of Excellence		$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
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
Ohio State University Medical Center	Transplant	Columbus	OH	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$434,000	25		$10,000	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
Ohio State University Medical Center	Transplant	Columbus	OH	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor: $175,000 \| Living Donor: $165,000	10		$10,000	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
Ohio State University Medical Center	Transplant	Columbus	OH	Pancreas	Pancreas	Adult	Member's Choice		$150,000	20		$10,000	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
Ohio State University Medical Center	Transplant	Columbus	OH	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	$250,000	20		$10,000	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
Ohio State University Medical Center	Transplant	Columbus	OH	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	$234,000	20		$10,000	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
Ohio State University Medical Center	Transplant	Columbus	OH	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	Single: $270,000 \| Bilateral: $275,000	30		$10,000	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
The Jewish Hospital - Cincinnati	Transplant	Cincinnati	OH	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$129,725	25		$3,153 Med/Surg \| $3,755 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
The Jewish Hospital - Cincinnati	Transplant	Cincinnati	OH	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$220,393	30		$3,153 Med/Surg \| $3,755 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
The Jewish Hospital - Cincinnati	Transplant	Cincinnati	OH	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$276,187	40		$3,153 Med/Surg \| $3,755 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
The Jewish Hospital - Cincinnati	Transplant	Cincinnati	OH	Tandem (Auto-to-Auto)	Tandem Auto to Auto	Adult	Member's Choice		$233,505	1st: 25 \| 2nd: 25		$3,153 Med/Surg \| $3,755 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
The Jewish Hospital - Cincinnati	Transplant	Cincinnati	OH	Tandem (Auto-to-Allo, Related)	Tandem Auto to Allo	Adult	Member's Choice		$294,269	1st: 25 \| 2nd: 30		$3,153 Med/Surg \| $3,755 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
The Jewish Hospital - Cincinnati	Transplant	Cincinnati	OH	Tandem (Auto-to-Allo, Unrelated)	Tandem Auto to Allo	Adult	Member's Choice		$348,723	1st: 25 \| 2nd: 30		$3,153 Med/Surg \| $3,755 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
University Hospitals Case Medical Center	Transplant	Cleveland	OH	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$157,385	30		Hospital: $5,474 \| 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
University Hospitals Case Medical Center	Transplant	Cleveland	OH	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$320,245	40		Hospital: $5,693 \| 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
University Hospitals Case Medical Center	Transplant	Cleveland	OH	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$320,245	40		Hospital: $5,693 \| 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
University Hospitals Case Medical Center	Transplant	Cleveland	OH	Heart	Heart	Adult	Member's Choice		$320,245	27		Hospital: $5,693 \| 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
University Hospitals Case Medical Center	Transplant	Cleveland	OH	Kidney	Kidney	Adult	Member's Choice		$145,177	12		Hospital: $5,693 \| 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
University Hospitals Case Medical Center	Transplant	Cleveland	OH	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$256,197	18		Hospital: $5,693 \| 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
University Hospitals Case Medical Center	Transplant	Cleveland	OH	Liver	Liver	Adult	Member's Choice		$263,312	20		Hospital: $5,693 \| 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
University Hospitals Case Medical Center	Transplant	Cleveland	OH	Lung	Lung	Adult	Member's Choice		$298,896	25		Hospital: $5,693 \| 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
University Hospitals Case Medical Center	Transplant	Cleveland	OH	Pancreas	Pancreas	Adult	Member's Choice		$167,952	16		Hospital: $5,693 \| 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
University Hospitals Case Medical Center	Transplant	Cleveland	OH	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		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
University Hospitals Case Medical Center	Transplant	Cleveland	OH	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		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
University Hospitals Case Medical Center	Transplant	Cleveland	OH	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		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
University Hospitals Case Medical Center	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 at Discharge	Ends One (1) Year from Discharge
University Hospitals Case Medical Center	Transplant	Cleveland	OH	Tandem (Auto-to-Auto)	Tandem Auto to Auto	Pediatric	Member's Choice		75% of Billed Charges	1st: 30 \| 2nd: 30					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
University Hospitals Case Medical Center	Transplant	Cleveland	OH	Tandem (Auto-to-Auto)	Tandem Auto to Auto	Adult	Member's Choice		1st: $163,679 \| 2nd: $120,982	30					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
University of Cincinnati Medical Center	Transplant	Cincinnati	OH	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		Hospital: $168,538 \| Professional: 75% of Billed Charges	30		$2,677 Med/Surg \| $3,348 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
University of Cincinnati Medical Center	Transplant	Cincinnati	OH	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		Hospital: $237,006 \| Professional: 75% of Billed Charges	30		$2,677 Med/Surg \| $3,348 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
University of Cincinnati Medical Center	Transplant	Cincinnati	OH	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		Hospital: $110,603 \| Professional: 75% of Billed Charges	30		$2,677 Med/Surg \| $3,348 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
University of Cincinnati Medical Center	Transplant	Cincinnati	OH	Heart	Heart	Adult	Member's Choice		Hospital: $262,287 \| Professional: 75% of Billed Charges	25		$2,677 Med/Surg \| $3,348 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
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
University of Cincinnati Medical Center	Transplant	Cincinnati	OH	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor, Hospital: $106,165 \| Cadaveric Donor, Professional: 75% of Billed Charges \| Living Donor, Hospital: $81,943 \| Living Donor, Professional: 75% of Billed Charges	12		$2,677 Med/Surg \| $3,348 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
University of Cincinnati Medical Center	Transplant	Cincinnati	OH	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $131,766 \| Professional: 75% of Billed Charges	15		$2,677 Med/Surg \| $3,348 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
University of Cincinnati Medical Center	Transplant	Cincinnati	OH	Liver	Liver	Adult	Member's Choice		Cadaveric Donor, Hospital: $210,672 \| Cadaveric Donor, Professional: 75% of Billed Charges \| Living Donor, Hospital: $250,649 \| Living Donor, Professional: 75% of Billed Charges	25		$2,677 Med/Surg \| $3,348 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
University of Cincinnati Medical Center	Transplant	Cincinnati	OH	Pancreas	Pancreas	Adult	Member's Choice		Hospital: $113,877 \| Professional: 75% of Billed Charges	15		$2,677 Med/Surg \| $3,348 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
Integris Baptist Medical Center	Transplant	Oklahoma City	OK	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	$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 when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
Integris Baptist Medical Center	Transplant	Oklahoma City	OK	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$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 when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
Integris Baptist Medical Center	Transplant	Oklahoma City	OK	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	$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 when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
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	N/A	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 when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
Integris Baptist Medical Center	Transplant	Oklahoma City	OK	Lung	Lung	Adult	Programs of Excellence	PerformanceELITE	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	N/A	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 when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
Integris Baptist Medical Center	Transplant	Oklahoma City	OK	Pancreas	Pancreas	Adult	Member's Choice		$75,000	15		$2,500 Med/Surg \| $2,500 ICU/CCU	90% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	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 when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
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	N/A	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 when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
Northwest Marrow Transplant Program	Transplant	Portland	OR	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	$136,696	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 $248,787, 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
Northwest Marrow Transplant Program	Transplant	Portland	OR	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	$153,380	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 $279,152, 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
Northwest Marrow Transplant Program	Transplant	Portland	OR	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	$141,045	N/A	65% of Billed Charges	N/A	87% of Billed Charges	70% of Billed Charges	Reimbursed at Invoice Cost	Reimbursed at Invoice Cost			If Billed Charges Exceed $256,702, 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
Northwest Marrow Transplant Program	Transplant	Portland	OR	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$161,453	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 $293,844, 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
Northwest Marrow Transplant Program	Transplant	Portland	OR	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$218,480	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 $397,634, 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
Northwest Marrow Transplant Program	Transplant	Portland	OR	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$233,568	N/A	65% of Billed Charges	N/A	87% of Billed Charges	70% of Billed Charges	Reimbursed at Invoice Cost	Reimbursed at Invoice Cost			If Billed Charges Exceed $425,094, 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
Oregon Health & Science University	Transplant	Portland	OR	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor: $112,623 \| Living Donor: $116,775	N/A			90% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	Cadaveric Donor: Charges that Exceed $202,721 Shall be Reimbursed at 65% of Billed Charges \| Living Donor: Charges that Exceed $210,195 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
Oregon Health & Science University	Transplant	Portland	OR	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$207,600	N/A			90% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	Charges that Exceed $373,680 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
Oregon Health & Science University	Transplant	Portland	OR	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	$193,068	N/A			90% of Billed Charges	70% of Billed Charges			Included in Case Rate	N/A	Charges that Exceed $328,216 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
Oregon Health & Science University	Transplant	Portland	OR	Heart	Heart	Adult	Member's Choice		$290,000	N/A		N/A	90% of Billed Charges	70% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	Charges that Exceed $522,000 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
Oregon Health & Science University	Transplant	Portland	OR	Kidney	Kidney	Pediatric	Programs of Excellence		Cadaveric Donor: $112,623 \| Living Donor: $116,775	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 $202,721 Shall be Reimbursed at 65% of Billed Charges \| Living Donor: Charges that Exceed $210,195 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
Children's Hospital of Philadelphia	Transplant	Philadelphia	PA	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		Hospital: $205,337 \| 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 ($316,035)	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge
Children's Hospital of Philadelphia	Transplant	Philadelphia	PA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		Hospital: $281,389 \| 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 ($432,646)	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge
Children's Hospital of Philadelphia	Transplant	Philadelphia	PA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		Hospital: $342,230 \| 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 ($527,288)	Begins at Evaluation	Begins on the Day of Ablative Therapy and Ends at Discharge	Ends One (1) Year from Discharge
Children's Hospital of Philadelphia	Transplant	Philadelphia	PA	Heart	Heart	Pediatric	Programs of Excellence		Hospital: $295,754 \|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 ($456,307)	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge
Children's Hospital of Philadelphia	Transplant	Philadelphia	PA	Heart/Lung	Heart/Lung	Pediatric	Member's Choice		Hospital: $329,555 \| 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 ($507,008)	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge
Children's Hospital of Philadelphia	Transplant	Philadelphia	PA	Kidney	Kidney	Pediatric	Programs of Excellence		Hospital: $144,497 \| 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 ($221,393)	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge
Children's Hospital of Philadelphia	Transplant	Philadelphia	PA	Liver	Liver	Pediatric	Programs of Excellence		Hospital: $228,154 \| 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 ($351,535)	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge
Children's Hospital of Philadelphia	Transplant	Philadelphia	PA	Lung	Lung	Pediatric	Programs of Excellence		Hospital: $312,655 \| 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 ($481,658)	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $147,376 \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	30		$3,126 ICU/CCU \| $2,431 Med/Surg	100% of Billed Charges	Hospital: 67% of Billed Charges \| Professional: 160% of Current Medicare RBRVS for the Philadelphia Geographic Area	Reimbursed at the Pre-Transplant Rate	N/A			40% of Billed Charges in Excess of 2.5 Times the Case Rate	Begins at Evaluation	Begins on the Day of Mobilization and Ends at Discharge	Ends One (1) Year from Discharge
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $255,970 \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	35		$3,126 ICU/CCU \| $2,431 Med/Surg	100% of Billed Charges	Hospital: 67% of Billed Charges \| Professional: 160% of Current Medicare RBRVS for the Philadelphia Geographic Area	Reimbursed at the Pre-Transplant Rate	N/A			40% of Billed Charges in Excess of 2.5 Times the Case Rate	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends at Discharge	Ends One (1) Year from Discharge
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $255,970 \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	40		$3,126 ICU/CCU \| $2,431 Med/Surg	100% of Billed Charges	Hospital: 67% of Billed Charges \| Professional: 160% of Current Medicare RBRVS for the Philadelphia Geographic Area	Reimbursed at the Pre-Transplant Rate	N/A			40% of Billed Charges in Excess of 2.5 Times the Case Rate	Begins at Evaluation	Begins on the Day of Preparative Therapy and Ends at Discharge	Ends One (1) Year from Discharge
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Heart/Lung	Heart/Lung	Adult	Member's Choice		Hospital: $504,183 \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	30		$3,126 ICU/CCU \| $2,431 Med/Surg	100% of Billed Charges	Hospital: 67% of Billed Charges \| Professional: 160% of Current Medicare RBRVS for the Philadelphia Geographic Area			Included in Case Rate	Reimbursed at Invoice Cost	40% of Billed Charges in Excess of 2.5 Times the Case Rate	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $459,173 \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	25		$3,126 ICU/CCU \| $2,431 Med/Surg	100% of Billed Charges	Hospital: 67% of Billed Charges \| Professional: 160% of Current Medicare RBRVS for the Philadelphia Geographic Area			Included in Case Rate	Reimbursed at Invoice Cost	40% of Billed Charges in Excess of 2.5 Times the Case Rate	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $155,133 \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	20		$3,126 ICU/CCU \| $2,431 Med/Surg	100% of Billed Charges	Hospital: 67% of Billed Charges \| Professional: 160% of Current Medicare RBRVS for the Philadelphia Geographic Area			Included in Case Rate	Reimbursed at Invoice Cost	40% of Billed Charges in Excess of 2.5 Times the Case Rate	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $201,674 \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	20		$3,126 ICU/CCU \| $2,431 Med/Surg	100% of Billed Charges	Hospital: 67% of Billed Charges \| Professional: 160% of Current Medicare RBRVS for the Philadelphia Geographic Area			Included in Case Rate	Reimbursed at Invoice Cost	40% of Billed Charges in Excess of 2.5 Times the Case Rate	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	Hospital: $279,241 \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	35		$3,126 ICU/CCU \| $2,431 Med/Surg	100% of Billed Charges	Hospital: 67% of Billed Charges \| Professional: 160% of Current Medicare RBRVS for the Philadelphia Geographic Area			Included in Case Rate	Reimbursed at Invoice Cost	40% of Billed Charges in Excess of 2.5 Times the Case Rate	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Lung	Lung	Adult	Member's Choice		Bilateral Lung Hospital: $364,562 \| Bilateral Lung Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area \| Single Lung Hospital: $345,493 \| Single Lung Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	35		$3,126 ICU/CCU \| $2,431 Med/Surg	100% of Billed Charges	Hospital: 67% of Billed Charges \| Professional: 160% of Current Medicare RBRVS for the Philadelphia Geographic Area			Included in Case Rate	Reimbursed at Invoice Cost	40% of Billed Charges in Excess of 2.5 Times the Case Rate	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge
Hospital of the University of Pennsylvania	Transplant	Philadelphia	PA	Pancreas	Pancreas	Adult	Member's Choice		Hospital: $147,377 \| Professional: 224% of Current Medicare RBRVS for the Philadelphia Geographic Area	20		$4,400 ICU/CCU \| $3,422 Med/Surg	100% of Billed Charges	Hospital: 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 in Excess of 2.5 Times the Case Rate	Begins at Evaluation	Begins on the Day of Admission and Ends at Discharge	Ends One (1) Year from Discharge
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $147,192 \| Professional: $12,360	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
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $197,260 \| Professional: $13,102	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
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceSELECT	Hospital: $225,001 \| Professional: $27,809	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
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Blood/Marrow (Tandem Autologous-to-Autologous)	Tandem Auto to Auto	Adult	Member's Choice		1st Auto: $104,495 \| 2nd Auto: $52,247	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
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Heart	Heart	Adult	Member's Choice		Hospital: $226,967 \| Professional: $38,202	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
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor Hospital: $102,248 \| Cadaveric Donor Professional: $12,809 \| Living Donor Hospital: $123,596 \| Living Donor Professional: $16,067	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
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $143,259 \| Professional: $25,281	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
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor Hospital: $217,978 \| Cadaveric Donor Professional: $41,798 \| Living Donor Hospital: $234,832 \| Living Donor Professional: $48,540	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
Thomas Jefferson University Hospital	Transplant	Philadelphia	PA	Pancreas	Pancreas	Adult	Member's Choice		Hospital: $102,248 \| Professional: $21,910	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
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
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
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	Charges Reimbursed at Cost Pass Through	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
Medical University of South Carolina	Transplant	Columbia	SC	Heart	Heart	Adult	Member's Choice		$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
Medical University of South Carolina	Transplant	Columbia	SC	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	$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
Medical University of South Carolina	Transplant	Columbia	SC	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceELITE	$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
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
Medical University of South Carolina	Transplant	Columbia	SC	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$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
Medical University of South Carolina	Transplant	Columbia	SC	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		$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
Medical University of South Carolina	Transplant	Columbia	SC	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$196,100	N/A		N/A	Lesser of 95%	75% of Billed Charges	Charges Reimbursed at Cost Pass Through	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
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
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
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
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
Avera McKennan Hospital	Transplant	Sioux Falls	SD	Kidney/Pancreas	Kidney/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
Avera McKennan Hospital	Transplant	Sioux Falls	SD	Liver	Liver	Adult	Member's Choice		$155,000	21		$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
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
Methodist University Hospital	Transplant	Memphis	TN	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	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
Methodist University Hospital	Transplant	Memphis	TN	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$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
Methodist University Hospital	Transplant	Memphis	TN	Liver	Liver	Adult	Member's Choice		$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
Methodist University Hospital	Transplant	Memphis	TN	Pancreas	Pancreas	Adult	Member's Choice		$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
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
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
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
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
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
St Jude Children's Research Hospital	Transplant	Memphis	TN	Blood/Marrow (Tandem)	Tandem Auto to Allo	Pediatric	Member's Choice		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
St Jude Children's Research Hospital	Transplant	Memphis	TN	Blood/Marrow (Tandem)	Tandem Auto to Auto	Pediatric	Member's Choice		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
Vanderbilt University Medical Center	Transplant	Nashville	TN	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceELITE	Inpatient: $85,000 \| Outpatient: $80,000	Inpatient: 20 \| Outpatient: 30		Hospital: $3,800 \| Professional: $200	90% of Billed Charges	80% 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
Vanderbilt University Medical Center	Transplant	Nashville	TN	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceELITE	Inpatient: $135,000 \| Outpatient: $125,000	Inpatient: 20 \| Outpatient: 30		Hospital: $3,800 \| Professional: $200	90% of Billed Charges	80% 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
Vanderbilt University Medical Center	Transplant	Nashville	TN	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceELITE	Inpatient: $160,000 \| Outpatient: $150,000	Inpatient: 20 \| Outpatient 30		Hospital: $3,800 \| Professional: $200	90% of Billed Charges	80% 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
Vanderbilt University Medical Center	Transplant	Nashville	TN	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$135,000	15		Hospital: $3,700 \| Professional: $300	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	Reimbursed at 54.6% 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
Vanderbilt University Medical Center	Transplant	Nashville	TN	Heart/Lung	Heart/Lung	Adult	Member's Choice		$168,516	15		Hospital: $3,700 \| Professional: $301	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	Reimbursed at 54.6% 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
Vanderbilt University Medical Center	Transplant	Nashville	TN	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$75,000	10		Hospital: $3,700 \| Professional: $300	90% of Billed Charges	80% 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
Vanderbilt University Medical Center	Transplant	Nashville	TN	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	$130,000	15		Hospital: $3,700 \| Professional: $300	90% of Billed Charges	80% 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
Vanderbilt University Medical Center	Transplant	Nashville	TN	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	Living Donor: $165,000 \| Cadaveric Donor: $150,000	15		Hospital: $3,700 \| Professional: $300	90% of Billed Charges	80% 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
Vanderbilt University Medical Center	Transplant	Nashville	TN	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	Single Lung: $158,000 \| Bilateral Lung: $180,000	15		Hospital: $3,700 \| Professional: $300	90% of Billed Charges	80% 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
Vanderbilt University Medical Center	Transplant	Nashville	TN	Pancreas	Pancreas	Adult	Member's Choice		$105,000	15		Hospital: $3,700 \| Professional: $300	90% of Billed Charges	80% 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
Vanderbilt University Medical Center	Transplant	Nashville	TN	Blood/Marrow (Autologous)	Autologous	Pediatric	Member's Choice		$96,000	20		Hospital: $3,800 \| Professional: $200	90% of Billed Charges	80% 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
Vanderbilt University Medical Center	Transplant	Nashville	TN	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Member's Choice		Inpatient: $150,000 \| Outpatient: $145,000	Inpatient: 20 \| Outpatient: 30		Hospital: $3,800 \| Professional: $200	90% of Billed Charges	80% 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
Vanderbilt University Medical Center	Transplant	Nashville	TN	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Member's Choice		$185,000	20		Hospital: $3,800 \| Professional: $200	90% of Billed Charges	80% 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
Vanderbilt University Medical Center	Transplant	Nashville	TN	Heart	Heart	Pediatric	Programs of Excellence		(0 - 4 Years): $185,000 \| (5 - 17 Years): $150,000	15		Hospital: $3,700 \| Professional: $300	90% of Billed Charges	80% of Billed Charges			Included in Case Rate	Reimbursed at 54.6% 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
Vanderbilt University Medical Center	Transplant	Nashville	TN	Kidney	Kidney	Pediatric	Member's Choice		$85,000	10		Hospital: $3,700 \| Professional: $300	90% of Billed Charges	80% 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
Baylor All Saints Medical Center	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
Baylor All Saints Medical Center	Transplant	Fort Worth	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
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
Baylor University Medical Center	Transplant	Dallas	TX	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		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
Baylor University Medical Center	Transplant	Dallas	TX	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		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
Baylor University Medical Center	Transplant	Dallas	TX	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		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
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
Baylor University Medical Center	Transplant	Dallas	TX	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	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
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
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
Baylor University Medical Center	Transplant	Dallas	TX	Lung	Lung	Adult	Programs of Excellence	PerformanceELITE	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
CHI St Luke's Health Baylor College of Medicine Medical Center	Transplant	Houston	TX	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	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
CHI St Luke's Health Baylor College of Medicine Medical Center	Transplant	Houston	TX	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	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
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
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
CHI St Luke's Health Baylor College of Medicine Medical Center	Transplant	Houston	TX	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	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
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
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
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
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
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
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
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
Houston Methodist Hospital	Transplant	Houston	TX	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceSELECT	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
Houston Methodist Hospital	Transplant	Houston	TX	Blood/Marrow (Allogeneic Unrelated)	Allogeneci Unrelated	Adult	Programs of Excellence	PerformanceSELECT	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
Houston Methodist Hospital	Transplant	Houston	TX	Blood/Marrow (Allogeneic Related)	Allogeneci Related	Adult	Programs of Excellence	PerformanceSELECT	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
Houston Methodist Hospital	Transplant	Houston	TX	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	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
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
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
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
Houston Methodist Hospital	Transplant	Houston	TX	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceELITE	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
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
Houston Methodist Hospital	Transplant	Houston	TX	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	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
Houston Methodist Hospital	Transplant	Houston	TX	Pancreas	Pancreas	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
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
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
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
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
Methodist Dallas Medical Center	Transplant	Dallas	TX	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor: $96,775 \| Living Donor: $89,138	10		$4,207 Med/Surg \| $5,073 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
Methodist Dallas Medical Center	Transplant	Dallas	TX	Kidney/Liver	Kidney/Liver	Adult	Member's Choice		$271,711	16		$4,643 Med/Surg \| $5,073 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
Methodist Dallas Medical Center	Transplant	Dallas	TX	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$159,661	12		$4,207 Med/Surg \| $5,073 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
Methodist Dallas Medical Center	Transplant	Dallas	TX	Liver	Liver	Adult	Member's Choice		$218,500	15		$4,207 Med/Surg \| $5,073 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
Scott and White Memorial Hospital	Transplant	Temple	TX	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$127,000	N/A		N/A	90% of Billed Charges	70% of Billed Charges	Included in Case Rate	N/A			If Billed Charges Exceed $254,000, 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
Scott and White Memorial Hospital	Transplant	Temple	TX	Heart	Heart	Adult	Member's Choice		$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
Scott and White Memorial Hospital	Transplant	Temple	TX	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$99,000	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 $198,000, 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
Scott and White Memorial Hospital	Transplant	Temple	TX	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$142,000	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 $284,000, 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
Scott and White Memorial Hospital	Transplant	Temple	TX	Pancreas	Pancreas	Adult	Member's Choice		$113,000	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 $226,000, 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
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
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
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
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
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
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
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
Texas Transplant Institute	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 Preparative Therapy and Ends When the IInlier Days Have Expired	Ends 90 Days from Discharge
Texas Transplant Institute	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 IInlier Days Have Expired	Ends 90 Days from Discharge
Texas Transplant Institute	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 IInlier Days Have Expired	Ends 90 Days from Discharge
Texas Transplant Institute	Transplant	San Antonio	TX	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$130,000	15		$1,500 Med/Surg \| $2,500 ICU/CCU	75% of Billed Charges	75% of Billed Charges			Included in Case Rate	Reimbursed at Invoice Cost	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ending the Day of Discharge	Ends 90 Days from Discharge
Texas Transplant Institute	Transplant	San Antonio	TX	Kidney	Kidney	Adult	Programs of Excellence	PerformanceQUALITY	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			Included in Case Rate	N/A	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant	Ends 90 Days from Discharge
Texas Transplant Institute	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			Included in Case Rate	N/A	55% of Billed Charges	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ending the Day of Discharge	Ends 90 Days from Discharge
Texas Transplant Institute	Transplant	San Antonio	TX	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	$120,000	15		$1,500 Med/Surg \| $2,500 ICU/CCU	75% 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 Ending the Day of Discharge	Ends 90 Days from Discharge
Texas Transplant Institute	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
Texas Transplant Institute	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 Preparative Therapy and Ends When the Inlier Days Have Expired	Ends 90 Days from Discharge
Texas Transplant Institute	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
Texas Transplant Institute	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
University Hospital - University Health System	Transplant	San Antonio	TX	Kidney	Kidney	Adult	Member's Choice		Cadaveric Donor \| Hospital: $79,500 \| Physician: $21,520 \| Living Donor \| Hospital: $70,500 \| Physician: $26,303	N/A		N/A	90% of Billed Charges	75% of Billed Charges			Reimbursed at Invoice Cost	N/A	2.5 Times the Case Rate & 70% of Billed Charges Thereafter	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge
University Hospital - University Health System	Transplant	San Antonio	TX	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	Cadaveric Donor \| Hospital: $153,500 \| Physician: $60,973 \| Living Donor \| Hospital: $144,000 \| Physician: $65,158	N/A		N/A	90% of Billed Charges	75% of Billed Charges			Reimbursed at Invoice Cost	N/A	2.5 Times the Case Rate & 70% of Billed Charges Thereafter	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge
University Hospital - University Health System	Transplant	San Antonio	TX	Lung	Lung	Adult	Programs of Excellence	PerformanceELITE	Single Lung \|Hospital: $181,750 \| Physician: $45,431 \| Bilateral Lung \| Hospital: $227,000 \| Physician: $50,214	N/A		N/A	90% of Billed Charges	75% of Billed Charges			Reimbursed at Invoice Cost	N/A	2.5 Times the Case Rate & 70% of Billed Charges Thereafter	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge
University Hospital - University Health System	Transplant	San Antonio	TX	Kidney	Kidney	Pediatric	Member's Choice		Cadaveric Donor \| Hospital: $76,500 \| Physician: $22,716 \| Living Donor \| Hospital: $68,000 \| Physician: $28,694	N/A		N/A	90% of Billed Charges	75% of Billed Charges			Reimbursed at Invoice Cost	N/A	2.5 Times the Case Rate & 70% of Billed Charges Thereafter	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge
University Hospital - University Health System	Transplant	San Antonio	TX	Liver	Liver	Pediatric	Member's Choice		Cadaveric Donor \| Hospital: $153,500 \| Physician: $60,973 \| Living Donor \| Hospital: $144,000 \| Physician: $65,158	N/A		N/A	90% of Billed Charges	75% of Billed Charges			Reimbursed at Invoice Cost	N/A	2.5 Times the Case Rate & 70% of Billed Charges Thereafter	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge
University Hospital - University Health System	Transplant	San Antonio	TX	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		Hospital: $107,750 \| Physician: $31,084	N/A		N/A	90% of Billed Charges	75% of Billed Charges			Reimbursed at Invoice Cost	N/A	2.5 Times the Case Rate & 70% of Billed Charges Thereafter	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge
UT Southwestern Medical Center	Transplant	Dallas	TX	Blood/Marrow (Autologous)	Autologous	Adult	Member's Choice		$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
UT Southwestern Medical Center	Transplant	Dallas	TX	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Member's Choice		$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
UT Southwestern Medical Center	Transplant	Dallas	TX	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Member's Choice		$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
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	2 Times the Case Rate, Plus any Applicable Per Diems	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
UT Southwestern Medical Center	Transplant	Dallas	TX	Kidney	Kidney	Adult	Member's Choice		$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
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 when Inlier and any Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
UT Southwestern Medical Center	Transplant	Dallas	TX	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	$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
UT Southwestern Medical Center	Transplant	Dallas	TX	Heart & Lung	Heart/Lung	Adult	Programs of Excellence	PerformanceSELECT	$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	2 Times the Case Rate, Plus any Applicable Per Diems	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
UT Southwestern Medical Center	Transplant	Dallas	TX	Cord Blood	Cord Blood	Adult	Programs of Excellence	PerformanceSELECT	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
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
UT Southwestern Medical Center	Transplant	Dallas	TX	Pancreas	Pancreas	Adult	Member's Choice		$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
University of Utah Medical Center	Transplant	Salt Lake City	UT	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$111,280	40		$2,288	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
University of Utah Medical Center	Transplant	Salt Lake City	UT	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$153,920	40		$2,288	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
University of Utah Medical Center	Transplant	Salt Lake City	UT	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$171,600	40		$2,288	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
University of Utah Medical Center	Transplant	Salt Lake City	UT	Heart	Heart	Adult	Programs of Excellence	PerformanceELITE	$109,200	25		$2,288	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
University of Utah Medical Center	Transplant	Salt Lake City	UT	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	$95,400	16		$2,288	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
University of Utah Medical Center	Transplant	Salt Lake City	UT	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor: $46,800 \| Living Donor: $65,000	16		$2,288	90% of Billed Charges	80% of Billed Charges			Cadaveric Donor, Reimbursed at Invoice Cost \| Living Donor, Included in the Transplant 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
University of Utah Medical Center	Transplant	Salt Lake City	UT	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	Cadaveric Donor: $130,000 \| Living Donor: $152,000	20		$2,288	90% of Billed Charges	80% of Billed Charges			Cadaveric Donor, Reimbursed at Invoice Cost \| Living Donor, Included in the Transplant 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
University of Utah Medical Center	Transplant	Salt Lake City	UT	Lung	Lung	Adult	Member's Choice		$130,000	24		$2,288	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
University of Utah Medical Center	Transplant	Salt Lake City	UT	Pancreas	Pancreas	Adult	Member's Choice		$72,000	16		$2,288	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
Seattle Cancer Care Alliance	Transplant	Seattle	WA	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceELITE	$239,799	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
Seattle Cancer Care Alliance	Transplant	Seattle	WA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceELITE	Matched: $348,712 \| Mismatched: $401,374	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
Seattle Cancer Care Alliance	Transplant	Seattle	WA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceELITE	$488,196	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
Seattle Cancer Care Alliance	Transplant	Seattle	WA	Blood/Marrow (Autologous)	Autologous	Pediatric	Programs of Excellence		$266,445	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
Seattle Cancer Care Alliance	Transplant	Seattle	WA	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Pediatric	Programs of Excellence		Matched: $392,833 \| Mismatched: $439,804	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
Seattle Cancer Care Alliance	Transplant	Seattle	WA	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Pediatric	Programs of Excellence		$536,589	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
Seattle Children's Hospital	Transplant	Seattle	WA	Heart	Heart	Pediatric	Programs of Excellence		Hospital: $206,647 \| Professional: $51,305	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 One (1) Day Prior to Transplant and Ends at Discharge	Ends 90 Days from Discharge
Seattle Children's Hospital	Transplant	Seattle	WA	Intestine	Intestine	Pediatric	Member's Choice		80% of Billed Charges	N/A		N/A	NA	80% of Billed Charges			Included in Case Rate	Reimbursed at 85% of Billed Charges	NA	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 90 Days from Discharge
Seattle Children's Hospital	Transplant	Seattle	WA	Intestine/Liver	Intestine/Liver	Pediatric	Member's Choice		80% of Billed Charges	N/A		N/A	NA	80% of Billed Charges			Included in Case Rate	Reimbursed at 85% of Billed Charges	NA	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends 90 Days from Discharge
Seattle Children's Hospital	Transplant	Seattle	WA	Kidney	Kidney	Pediatric	Programs of Excellence		Cadaveric Donor: Hospital: $83,605 \| Professional: $21,199 \| Living Donor: Hospital: $84,834 \| Professional: $21,121	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 One (1) Day Prior to Transplant and Ends at Discharge	Ends 90 Days from Discharge
Seattle Children's Hospital	Transplant	Seattle	WA	Liver	Liver	Pediatric	Programs of Excellence		Cadaveric Donor Hospital: $201,187 \| Cadaveric Donor Professional: $49,137 \| Living Donor Hospital: $201,187 \| Living Donor Professional: $49,601	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 One (1) Day Prior to Transplant and Ends at Discharge	Ends 90 Days from Discharge
Swedish Medical Center	Transplant	Seattle	WA	Kidney	Kidney	Adult	Member's Choice		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
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
Swedish Medical Center	Transplant	Seattle	WA	Liver	Liver	Adult	Programs of Excellence	PerformanceQUALITY	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
Swedish Medical Center	Transplant	Seattle	WA	Pancreas	Pancreas	Adult	Member's Choice		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
University of Washington Medical Center	Transplant	Seattle	WA	Heart	Heart	Adult	Programs of Excellence	PerformanceELITE	Hospital: $175,000 \| Professional: 75% of Billed Charges	N/A		N/A	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	During Transplant Phase: Charges Included in Case Rate\| Outside Transplant Phase: Charges Reimbursed at 75% of Billed Charges	Hospital: $300,000 & 76% of Billed Charges Thereafter	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge
University of Washington Medical Center	Transplant	Seattle	WA	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	Hospital: $95,000 \| Professional: 75% of Billed Charges	N/A		N/A	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	Hospital: $150,000 & 76% of Billed Charges Thereafter	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge
University of Washington Medical Center	Transplant	Seattle	WA	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $150,000 \| Professional: 75% of Billed Charges	N/A		N/A	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	Hospital: $255,000 & 76% of Billed Charges Thereafter	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge
University of Washington Medical Center	Transplant	Seattle	WA	Liver	Liver	Adult	Programs of Excellence	PerformanceELITE	Hospital: $155,000 \| Professional: 75% of Billed Charges	N/A		N/A	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	Hospital: $258,000 & 76% of Billed Charges Thereafter	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge
University of Washington Medical Center	Transplant	Seattle	WA	Lung	Lung	Adult	Programs of Excellence	PerformanceQUALITY	Single Lung Hospital: $170,000 \| Single Lung Professional: 75% of Billed Charges \| Bilateral Lung Hospital: $175,000 \| Bilateral Lung Professional: 75% of Billed Charges	N/A		N/A	80% of Billed Charges	75% of Billed Charges			Included in Case Rate	N/A	Single Lung \| Hospital: $275,000 & 76% of Billed Charges Thereafter \| Bilateral Lung \| $290,000 & 76% of Billed Charges Thereafter	Begins at Evaluation	Begins One (1) Day Prior to Transplant and Ends at Discharge	Ends One (1) Year from Discharge
University of Washington Medical Center	Transplant	Seattle	WA	Multi-Visceral	Multi-Visceral	Adult	Member's Choice		Hospital: 72% of Billed Charges \| Professional: 75% of Billed Charges	N/A		N/A	N/A	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
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 at Discharge	Ends 180 Days from Discharge
Aurora St Luke's Medical Center	Transplant	Milwaukee	WI	Heart	Heart	Adult	Member's Choice		$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
Aurora St Luke's Medical Center	Transplant	Milwaukee	WI	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	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
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
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
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 One (1) Year from Discharge
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 One (1) Year from Discharge
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 One (1) Year from Discharge
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 One (1) Year from Discharge
Children's Hospital of Wisconsin	Transplant	Milwaukee	WI	Lung	Lung	Pediatric	Programs of Excellence		$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 One (1) Year from Discharge
Children's Hospital of Wisconsin	Transplant	Milwaukee	WI	Heart & Lung	Heart & Lung	Pediatric	Programs of Excellence		$198,000	35		$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 One (1) Year from Discharge
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 One (1) Year from Discharge
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 One (1) Year from Discharge
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 One (1) Year from Discharge
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceELITE	$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 from Discharge
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceELITE	$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 from Discharge
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceELITE	$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 from Discharge
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Blood/Marrow (Tandem Auto to Auto)	Tandem Auto to Auto	Adult	Programs of Excellence	PerformanceELITE	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 from Discharge
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Blood/Marrow (Tandem Auto to Allo)	Tandem Auto to Allo	Adult	Programs of Excellence	PerformanceELITE	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 from Discharge
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Heart	Heart	Adult	Member's Choice		$125,000	20		3200	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 from Discharge
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Kidney	Kidney	Adult	Member's Choice		Cadaveric Donor: $54,000 \| Living Donor: $59,000	17		$1,500 Med/Surg \| $1,800 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 from Discharge
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Kidney/Pancreas	Kidney/Pancreas	Adult	Member's Choice		$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 from Discharge
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Liver	Liver	Adult	Member's Choice		$140,000	20		$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 from Discharge
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Lung	Lung	Adult	Member's Choice		$160,000	20		$3,200 Med/Surg \| $3,200 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 from Discharge
Froedtert Memorial Lutheran Hospital	Transplant	Milwaukee	WI	Pancreas	Pancreas	Adult	Member's Choice		$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 from Discharge
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $105,525 \| Professional: $9,627	21		Hospital: $4,711 \| Professional: $715	90% of Billed Charges	Inpatient: $4,711 Per Diem \| Outpatient & Professional: 70% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends when Inlier Days and Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	Hospital $164,248 \| Professional: $17,804	35		Hospital: $4,711 \| Professional: $715	90% of Billed Charges	Inpatient: $4,711 Per Diem \| Outpatient & Professional: 70% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends when Inlier Days and Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	Hospital $295,471 \| Professional: $19,438	35		Hospital: $4,711 \| Professional: $715	90% of Billed Charges	Inpatient: $4,711 Per Diem \| Outpatient & Professional: 70% of Billed Charges	Included in Case Rate	Included in Case Rate			50% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends when Inlier Days and Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Heart	Heart	Adult	Programs of Excellence	PerformanceQUALITY	Hospital: $211,856 \| Professional: $68,545	13		Hospital: $4,711 \| Professional: $715	90% of Billed Charges	Inpatient: $4,711 Per Diem \| Outpatient & Professional: 70% of Billed Charges			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends when Inlier Days and Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Kidney	Kidney	Adult	Programs of Excellence	PerformanceELITE	Hospital: $84,752 \| Professional: $27,542	7		Hospital: $4,711 \| Professional: $715	90% of Billed Charges	Inpatient: $4,711 Per Diem \| Outpatient & Professional: 70% of Billed Charges			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends when Inlier Days and Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceSELECT	Hospital $147,457 \| Professional: $45,125	12		Hospital: $4,711 \| Professional: $715	90% of Billed Charges	Inpatient: $4,711 Per Diem \| Outpatient & Professional: 70% of Billed Charges			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends when Inlier Days and Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	Cadaveric Donor Hospital: $127,430 \| Cadaveric Donor Professional: $86,825 \| Living Donor Hospital: $144,145 \| Living Donor Professional: $120,525	Cadaveric Donor: 19 \| Living Donor: 21		Hospital: $4,711 \| Professional: $715	90% of Billed Charges	Inpatient: $4,711 Per Diem \| Outpatient & Professional: 70% of Billed Charges			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends when Inlier Days and Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
University of Wisconsin Hospital and Clinics	Transplant	Madison	WI	Lung	Lung	Adult	Programs of Excellence	PerformanceSELECT	Single Lung \| Hospital: $176,719 \| Professional: $45,678 \| Bilateral Lung \| Hospital: $320,476 \| Professional: $74,334	Single Lung: 15 \| Bilateral Lung: 20		Hospital: $4,711 \| Professional: $715	90% of Billed Charges	Inpatient: $4,711 Per Diem \| Outpatient & Professional: 70% of Billed Charges			Included in Case Rate	Ventricular Assist Device (VAD) Shall be Reimbursed at 70% of Billed Charges	50% of Billed Charges	Begins at Evaluation	Begins on the Day of Admission and Ends when Inlier Days and Applicable Outlier Days have Expired	Ends One (1) Year from Discharge
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
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
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
Indiana University Hospital	Cellular Immunotherapy	Indianapolis	IN	Cellular Immunotherapy	Cellular Immunotherapy				$228,800 \| Drug Cost: 100% of Invoice Cost	N/A		N/A	80% of Billed Charges	65% of Billed Charges					If Charges Exceed $468,000, 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
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
Mt 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
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
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
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
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
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
Mayo Clinic Hospital (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
Rochester Methodist Hospital (Mayo Clinic)	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
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
Oregon Health & Science University	Cellular Immunotherapy	Portland	OR	Cellular Immunotherapy	Cellular Immunotherapy				70% of Billed Charges \| 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 One (1) Year from Discharge
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
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
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
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 the State of Maryland HSCRC rates \| 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 90 Days from Discharge
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
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
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
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
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
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
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
University of Maryland Medical System	Cellular Immunotherapy	Baltimore	MD	Cellular Immunotherapy	Cellular Immunotherapy				Hospital: 100% of HSCRC Fee Schedule \| Physicians: 75% of Billed Charges \| CAR-T Drug: 100% of Billed Charges	N/A		N/A	N/A	Hospital: 100% of the State of Maryland HSCRC rates \| 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 90 Days from Discharge
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
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
Aurora St Luke's Medical Center	Transplant	Milwaukee	WI	Heart	Heart	Adult	Member's Choice		$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
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
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
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
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
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
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	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
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
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				110% 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
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
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
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
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	Outpatient Care: 75% of Billed Charges				75% of Billed Charges	Inpatient Services: Lesser of 80% of Billed Charges or $7,500, but never less than 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
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% ($752,400) 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
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: $2,288	Inpatient Services: Lesser of 90% of Billed Charges or $2,288	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
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
Thomas Jefferson University Hospital	Destination VAD	Philadelphia	PA	Destination VAD	Destination VAD				Surgical Event: 70% of Billed Charges	N/A		Inpatient Per Diem: $3,976	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
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	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
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
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
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
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
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: $5,000 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
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
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
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
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: $2,970 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	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
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: $3,500 Per Diem \| Inpatient (Med/Surg) Professional: 60% of Billed Charges \| Inpatient (NICU/PICU) Hospital: $6,500 Per Diem \| Inpatient (NICU/PICU) Professional 60% of Billed Charges \| Inpatient (CICU): $7,500 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
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
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
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 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
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
Oregon Health & Science University	Bariatric	Portland	OR	Bariatric	Bariatric				Gastric Banding, Realize Band, Lap-Band: $17,160 \| Gastric Bypass, Biliopancreatic Bypass: $28,080 \| Gastric Sleeve: $17,420 \| Duodenal Switch: $30,680 \| Professional: 75% of Billed Charges	Gastric Banding, Realize Band, Lap-Band: 2 \| Gastric Bypass, Biliopancreatic Bypass: 3 \| Gastric Sleeve: 2 \| Duodenal Switch: 3		Hospital: $5,044 \| 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
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
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
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
Froedtert Memorial Lutheran Hospital	Bariatric	Milwaukee	WI	Bariatric	Bariatric				Gastric Banding: $32,011 \| Gastric Bypass: $33,911 \| Gastric Sleeve: $21,810	Gastric Banding: 2 \| Gastric Bypass: 3 \| Gastric Sleeve: 2		$3,519	100% 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
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
Medical University of South Carolina	Bariatric	Columbia	SC	Bariatric	Bariatric				Duodenal Switch: $27,870 \| Gastric Banding: $12,649 \| Gastric Bypass: $20,870 \| Gastric Sleeve: $18,912	Duodenal Switch: 3 \| Gastric Banding: 1 \| Gastric Bypass: 3 \| Gastric Sleeve: 2		$3,000	95% of Billed Charges	75% 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
Thomas Jefferson University Hospital	Bariatric	Philadelphia	PA	Bariatric	Bariatric				Duodenal Switch: $19,056 \| Gastric Banding: $17,865 \| Gastric Bypass: Hospital: $20,247; Professional: $5,598 \| Gastric Sleeve: Hospital: $29,775; Professional $4,883	Duodenal Switch: 3 \| Gastric Banding: 2 \| Gastric Bypass: 3 \| Gastric Sleeve: 2		$2,978	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
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
City of Hope National Medical Center	Cancer	Duarte	CA	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
University of California San Francisco Medical Center	Cancer	San Francisco	CA	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
Memorial Sloan-Kettering Cancer Center	Cancer	New York	NY	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
St Jude Children's Research Hospital	Cancer	Memphis	TN	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
Seattle Cancer Care Alliance	Cancer	Seattle	WA	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
University of Wisconsin Hospital and Clinics	Cancer	Madison	WI	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
Stanford Health Care	Cancer	Palo Alto	CA	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
University of Utah Medical Center	Cancer	Salt Lake City	UT	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
Mayo Clinic Hospital (Arizona)	Cancer	Phoenix	AZ	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
University of Colorado Hospital	Cancer	Aurora	CO	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
Rochester Methodist Hospital (Mayo Clinic)	Cancer	Rochester	MN	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
The Nebraska Medical Center	Cancer	Omaha	NE	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
UT Southwestern Medical Center	Cancer	Dallas	TX	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
University of Michigan Medical Center	Cancer	Ann Arbor	MI	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
Johns Hopkins Hospital	Cancer	Baltimore	MD	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
Duke University Hospital	Cancer	Durham	NC	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
Mayo Clinic Florida	Cancer	Jacksonville	FL	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
Dana-Farber Cancer Institute	Cancer	Boston	MA	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
IUH - Indiana University Medical Center	Cancer	Indianapolis	IN	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
MD Anderson Cancer Center	Cancer	Houston	TX	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
Moffitt Cancer Center	Cancer	Tampa	FL	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
Medical University of South Carolina	Cancer	Columbia	SC	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
University of California San Diego Medical Center	Cancer	San Diego	CA	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
Oregon Health & Science University	Cancer	Portland	OR	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
University of Iowa Hospitals and Clinics	Cancer	Iowa City	IA	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
University Hospitals of Cleveland	Cancer	Cleveland	OH	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
University of Alabama Hospital	Cancer	Birmingham	AL	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
Vanderbilt University Medical Center	Cancer	Nashville	TN	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
Northwestern Memorial Hospital	Cancer	Chicago	IL	Cancer	Cancer				Contact INTERLINK for Contract Details \| 800-599-9119
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
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
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
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
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
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
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
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
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
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
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
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
Keck Hospital of USC	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
Keck Hospital of USC	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
Keck Hospital of USC	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
Keck Hospital of USC	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
Keck Hospital of USC	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
Keck Hospital of USC	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
Keck Hospital of USC	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
Keck Hospital of USC	Transplant	Los Angeles	CA	Multi-Organ	Multi-Organ	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
Stanford Hospital	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
Stanford Hospital	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
Stanford Hospital	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
Stanford Hospital	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
Stanford Hospital	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
Stanford Hospital	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
Stanford Hospital	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
Stanford Hospital	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
Stanford Hospital	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
Stanford Hospital	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
University of California San Diego Medical Center	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
University of California San Diego Medical Center	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
University of California San Diego Medical Center	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
University of California San Diego Medical Center	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
University of California San Diego Medical Center	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
University of California San Diego Medical Center	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
University of California San Diego Medical Center	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
University of California San Diego Medical Center	Transplant	San Diego	CA	Kidney/Pancreas	Kidney/Pancreas	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
University of California San Diego Medical Center	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
University of California San Diego Medical Center	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
University of California San Diego Medical Center	Transplant	San Diego	CA	Pancreas	Pancreas	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
University Hospital of San Antonio	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
University Hospital of San Antonio	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
University Hospital of San Antonio	Transplant	San Antonio	TX	Kidney/Pancreas	Kidney/Pancreas	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
University Hospital of San Antonio	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
University Hospital of San Antonio	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
University Hospital of San Antonio	Transplant	San Antonio	TX	Pancreas	Pancreas	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
University of Kansas Hospital	Transplant	Kansas City	KS	Blood/Marrow (Autologous)	Autologous	Adult	Programs of Excellence	PerformanceQUALITY	$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
University of Kansas Hospital	Transplant	Kansas City	KS	Blood/Marrow (Allogeneic Related)	Allogeneic Related	Adult	Programs of Excellence	PerformanceQUALITY	$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
University of Kansas Hospital	Transplant	Kansas City	KS	Blood/Marrow (Allogeneic Unrelated)	Allogeneic Unrelated	Adult	Programs of Excellence	PerformanceQUALITY	$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
University of Kansas Hospital	Transplant	Kansas City	KS	Heart	Heart	Adult	Programs of Excellence	PerformanceSELECT	$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 $275,000, 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
University of Kansas Hospital	Transplant	Kansas City	KS	Kidney	Kidney	Adult	Programs of Excellence	PerformanceSELECT	$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
University of Kansas Hospital	Transplant	Kansas City	KS	Kidney/Pancreas	Kidney/Pancreas	Adult	Programs of Excellence	PerformanceELITE	$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
University of Kansas Hospital	Transplant	Kansas City	KS	Liver	Liver	Adult	Programs of Excellence	PerformanceSELECT	$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
University of Kansas Hospital	Transplant	Kansas City	KS	Pancreas	Pancreas	Adult	Member's Choice		$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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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