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INTEGRATED CLINICAL & FINANCIAL HOSPITAL IT SOLUTIONS

Patient AccountingReport Book

Patient Accounting Contract Management & Payor Logs

Sample Reports

TABLE OF CONTENTS CONTRACT MANAGEMENT REPORTS

Patient Insurance Letters ...........................................................................1.1 Contract Calculation List ..........................................................................1.2 Payment Variance Report .........................................................................1.3 Contract Expiration Report .......................................................................1.4 Contract Modeling – Comparison Summary ............................................1.5

PAYOR LOGS

Detail Patient Log .....................................................................................2.1 Unbilled Claims ........................................................................................2.2 Billed Claims - Summary Log ..................................................................2.4 Bad Debt Payor Log..................................................................................2.5

CONTRACT MANAGEMENT FILE LISTINGS

Payor Plan File ..........................................................................................3.1 Contract Header Listing ............................................................................3.2 Contract Detail Listing ..............................................................................3.3 Contract Category Listing .........................................................................3.4 Stop / Loss Listing ....................................................................................3.5 Revenue Set Listing ..................................................................................3.6 ASC Payment Group Listing ....................................................................3.7 DRG Terms Listing...................................................................................3.8 CPT Procedures Listing ............................................................................3.9

Contract Management Insurance Eligibility / Contract Management Page 1.1

PATIENT INSURANCE LETTERS CMPTDETAIL HMS HOSPITAL CLEWIS 3102 WEST END AVENUE NASHVILLE TN 37203-0000 Insurance Name MEDICARE Patient Name SIMMS JO HELEN Address 730 CHESTNUT STREET Patient# 3241384-01 City/St CHATTANOOGA TN Insureds Name SIMMS JO HELEN Insurance ID 410305580B Group Number Treatment Number 1255 Contract Name CITY OF NASHVILLE Service Date From 4/26/10 Contract Effective Date 1/01/10 Service Date To 5/10/10 Contract Category Date Billed Dear Sir/Madam: This bill reflects the payment due for the above patient per our contract terms. Total Billed Charges $ 2,764.00 Total Non-Covered Charges $ 7,575.00 Contractual Amount for Consideration $ 2,542.88 Category Covered Amount Total Expected Payment $ 221.12 Disallowances Actual Deductible $ .00 Actual Coinsurance Amount $ .00 Net Due from Payer $ .00 Payment Received on 5/16/10 $ 50.00- Payment Error $ 117.12 Please pay the amount shown as the Payment Error


CONTRACT CALCULATION LIST PA0R51 HMS HOSPITAL PAGE: 1 USER: CLEWIS Selected by: Bill Date MONITOR CONTRACT MANAGEMENT FORMULA CALCULATION DATE: 8/07/10 HOSPITAL: 001 Sorted by: Patient Name BILL DATE FROM 01/01/2010 TO 07/31/2010 TIME: 15:06:22 ==================================================================================================================================== PAT#/CYCLE# 1041491 1 SIMMS BETTY ORIGINAL BALANCE: 2,000.00 ADMIT DTE: 07/17/2010 DISCHG DTE: 07/25/2010 INS#/NAME# 002 001 ABC INSURANCE CONT#/NAME: 00200 CITY OF NASHVILLE 01/01/2009 01/01/2011 FORMULA/ REV/DRG CPT CALCULATED BILL CAT# DESC STOP/LOSS DESC CODE DESC CODE DESC QTY RATE/AMT CHARGES DATE 1 EMERGENCY 2 PER CASE 225.00 225.00 08/10/2010 TOTAL .00 ==================================================================================================================================== PAT#/CYCLE# 3241384 1 SIMMS JO HELEN ORIGINAL BALANCE: 5,548.90 ADMIT DTE: 04/26/2010 DISCHG DTE: 05/10/2010 INS#/NAME# 003 001 BCBSTN CONT#/NAME: 00300 ABC CONTRACT 04/04/2009 04/04/2011 FORMULA/ REV/DRG CPT CALCULATED BILL CAT# DESC STOP/LOSS DESC CODE DESC CODE DESC QTY RATE/AMT CHARGES DATE 140 IP SURGICAL 1 PER DIEM 120 ROOM-BOARD/SEMI 9 900.00 8,100.00 06/10/2010 140 IP SURGICAL 3 PERCENT 274 PROSTH/ORTH DEV .55 293.77 TOTAL 8,393.77


PAYMENT VARIANCE REPORT HMS HOSPITAL PAGE 1 PA0R541 MONITOR CONTRACT PAYMENT VARIANCE REPORT DATE 8/07/10 FOR THE PAYMENT PERIOD 1/01/10 THRU 1/31/10 TIME 14:32:31 CONTRACT # 00000 PAYOR 000 000 PATIENT DATE DATE BILLED NON/COVERED APPROVED CONTRACTUAL EXPECTED ACTUAL NUMBER NAME BILLED PAID CHARGES DEDUCTIBLES CHARGES AMOUNT PAYMENT PAYMENT VARIANCE 103333-01 WARREN JANE R 1/08/10 1/28/10 3,659.50 50.00 3,609.50 2,034.17 1,800.12 1,625.33 174.79 103375-01 DOE MARY A 1/10/10 1/30/10 3,865.50 500.00 3,365.50 1,746.09 2,000.00 2,119.41 119.41- Payor Total 7,525.00 6,979.00 3,800.12 55.38 550.00 3,780.26 3,744.74 Contract Total 7,525.00 6,979.00 3,800.12 55.38 550.00 3,780.26 3,744.74 Final Total 7,525.00 6,979.00 3,800.12 55.38 550.00 3,780.26 3,744.74


CONTRACT EXPIRATION REPORT PA0R55 HMS HOSPITAL 14:32:37 Contract Expiration Report 8/07/10 Contracts Expiring within 90 Days Contract Nbr Contract Name Beginning Date Ending Date 00100 DEVOID CTY SCHOOLS 09/01/2010 09/01/2011 00200 CITY OF NASHVILLE 01/01/2010 01/01/2011 02002 TARGET EMPLOYEES UNI 01/01/2010 12/31/2011


CONTRACT MODELING – COMPARISON SUMMARY

HMS HOSPITAL CONTRACT COMPARISON SUMMARY 1/01/10 THROUGH 12/30/10

CONTRACT: 200 CITY OF NASHVILLE ACTIVE CONTRACT CITY OF NASHVILLE SCENARIO: 1 ===================================================================== Number of Cases 10 20 Gross Charges 40,550.00 52,750.00 Non Covered Gross Charges Adjusted 5,488.00 6,960.00 Net. Revenue Expected 20,340.00 25,303.00 Stop Loss Amount .00 .00 Deductible/Co-Pay 2,000.00 2,000.00 Expected Payment 20,555.00 23,400.00 Contractual Adjustment Expected PCR%

Contract Management Payor Logs Page 2.1

DETAIL PATIENT LOGS MED005 HOSPITAL TYPE 1 HMS HOSPITAL DATE: 8/07/10 PAGE 1 BILL CLASSIFICATION 3 MEDICARE TIME: 16:40:25 FINANCIAL CLASS(ES) M 3237545 01 ANDREWS WILLA CLAIM# 410669510A ADMIT 2/27/10 DISCH 2/27/10 ANCILLARY ----- ----- COMPONENTS ------ ---------- DEDUCTIBLES ----------- DESC DYS AMOUNT DESC AMOUNT DESC AMOUNT DESC AMOUNT NON-COVR 1 PHARMACY 17.60 PRO ANES .00 NON-COVERED .00 OBSERVAT .00 IV SOL/P .00 PRO ER .00 PATIENT .00 RESERVED .00 BLOOD .00 PRO EKG .00 BLOOD .00 RESERVED .00 CEN SUPP 442.42 PRO GEN .00 CO-INSURANCE .00 RESERVED .00 LAB .00 PRO PSYC .00 ------------ RESERVED .00 X-RAY .00 RESERVED .00 TOTAL .00 RESERVED .00 CT SCAN .00 ------------ ----- ------------ OR 381.60 TOTAL .00 TOTAL 1 .00 EKG/TELE .00 AMBULANC .00 RESP THP .00 ---------------------- PAYMENT SUMMARY ---------------------- NUC MED .00 SPCH PTH .00 OPERATING CAPITAL TOTAL PHY THER .00 PMT COMPUTED(NON-TRF) 639.80 .00 639.80 OTHER INFORMATION: E.R. .00 PMT COMPUTED(TRANSFR) .00 .00 .00 CARDIOLO .00 ------------ LOGGING DATE 4/10/10 RECOVERY .00 TOTAL PAYMENT 639.80 .00 639.80 PAYMENT DATE 4/18/10 EEG .00 ADD OUTLIER PMT .00 .00 .00 PHYSICIAN 324 GASTRO .00 LESS: DEDUCTIBLES .00 MDC CODE 00 GEN DIAG .00 ------------ DRG CODE 000 MAMMOGRA .00 EXPECTED PAYMENT 639.80 DRG WEIGHT .0000 ------------ TOTAL 841.62 ACTUAL PAYMENT 364.52 SUMMARY TOTAL CHARGES NON-COVER COVERED COMPONENT NET BILLED DEDUCTIBLE NET 841.62 .00 841.62 .00 841.62 .00 841.62


INPATIENT / OUTPATIENT UNBILLED CLAIMS DATE: 8/07/10 HMS HOSPITAL PAGE 1 TIME: 15:40:43 INPATIENT UNBILLED CLAIMS PB0R0M

FOR PERIOD ENDING: 12/31/10 PAYOR PLAN.. 002/003 MEDICARE-HHA PATIENT F BILLED FROM BILLED THRU DAYS/ BILL PER/ UNBILLED ESTIMATED CONTRACTUAL COVG NO. C PATIENT NAME DATE DATE VISITS FREQ DIEM AMOUNT PAYMENT AMOUNT TYPE 5001319 M ANDERTON EARL 4/16/10 4/27/10 11 1 225.00 10,175.46 2,475.00 7,700.46 01 PAYOR PLAN TOTALS --- 1 PATIENTS 11 10,175.46 2,475.00 7,700.46 /\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\ PAYOR PLAN.. 002/006 MEDICARE SWING BED PATIENT F BILLED FROM BILLED THRU DAYS/ BILL PER/ UNBILLED ESTIMATED CONTRACTUAL COVG NO. C PATIENT NAME DATE DATE VISITS FREQ DIEM AMOUNT PAYMENT AMOUNT TYPE 3251000 M FULLER ADA M 3/16/10 4/16/10 42 1 225.00 12,109.00 9,450.00 2,659.00 01 5001320 M ANDERTON THOMAS 4/17/10 4/25/10 8 1 225.00 9,010.77 1,800.00 7,210.77 01 5001321 M PARKER JAMES E 4/20/10 4/30/10 10 1 225.00 7,724.20 2,250.00 5,474.20 01 5001322 M FULLER ADA M 5/05/10 5/08/10 3 1 225.00 1,887.95 675.00 1,212.95 01 PAYOR PLAN TOTALS --- 4 PATIENTS 63 30,731.92 14,175.00 16,556.92 PAYOR TOTALS --------- 5 PATIENTS 74 40,907.38 16,650.00 24,257.38 DATE: 8/07/10 HMS HOSPITAL PAGE 5 TIME: 15:40:43 OUTPATIENT UNBILLED CLAIMS PB0R0M FOR PERIOD ENDING: 6/10/10 PAYOR PLAN.. 004/002 ACCESS M/PLUSOP PATIENT F BILLED FROM BILLED THRU DAYS/ BILL UNBILLED ESTIMATED CONTRACTUAL COVG NO. C PATIENT NAME DATE DATE VISITS FREQ PERCENT AMOUNT PAYMENT AMOUNT TYPE 3233061 Q BROWN ALEXANDRA PAIGE 4/26/10 4/26/10 1 41% 42.20 17.30 24.90 03 3233344 Q GAMBLE TRINITY 4/28/10 4/28/10 1 41% 73.30 30.05 43.25 03 3239067 Q PARKER DONALD 3/21/10 6/10/10 22 0 41% 1,374.20 563.42 810.78 03 3240196 Q BROWN CHRIS 4/06/10 4/06/10 1 41% 432.78 177.43 255.35 03 3240845 Q ODONNELL CAROL M 4/17/10 4/17/10 1 41% 174.00 71.34 102.66 03 3240853 Q SMITH HANK 4/17/10 4/17/10 1 41% .00 .00 .00 03 3241536 Q JACKSON ANDREA 4/27/10 4/27/10 1 41% 286.95 117.64 169.31 03 3241538 Q LANIUS CYNTHIA 4/27/10 4/28/10 1 41% 969.24 397.38 571.86 03 3241573 Q COLBURN LOGAN N 4/27/10 4/27/10 1 41% .00 .00 .00 03 3242030 Q ZIMMERMAN KATHY ANN 5/04/10 5/04/10 1 41% 664.50 272.44 392.06 03 3242088 Q ROGERS BARRY 5/06/10 5/06/10 1 41% .00 .00 .00 03 PAYOR PLAN TOTALS --- 11 PATIENTS 22 4,017.17 1,647.00 2,370.17 BILL FREQ KEY: 0 - ADMISSION THRU PERIOD END 2 - LAST BILL THRU PERIOD END 1 - ADMISSION THRU DISCHARGE 4 - LAST BILL THRU DISCHARGE


DISCHARGED UNBILLED CLAIMS PB0R0H HMS HOSPITAL PAGE 1 DISCHARGED UNBILLED CLAIMS DATE: 1/07/11 FOR PERIOD ENDING: 12/31/10 TIME: 15:40:43 PAYOR PLAN.. 002/001 MEDICARE PATIENT PATIENT ADMISSION DISCHARGE DRG STD ACT AMOUNT EXPECTED CONTRACTUAL NO. NAME DATE DATE LOS LOS CHARGED PAYMENT AMOUNT 1041460 HUMBOLT LAURA GAYDELL 4/13/10 4/13/10 000 .0 1 1,643.01 .00 1,643.01 1041461 ROBERTSON CHRISTINE W 4/13/10 4/19/10 000 .0 6 6,190.43 .00 6,190.43 1041463 UNDERWOOD DAYTON A 4/18/10 4/25/10 000 .0 7 7,796.78 .00 7,796.78 1041465 IGNAGNI GEORGIA BELL 4/20/10 4/24/10 000 .0 4 5,053.72 .00 5,053.72 1041488 ANDREWS WILLA 6/14/10 7/17/10 000 .0 30 7,845.75 .00 7,845.75 1041492 SIMMS BETTY 7/25/10 8/21/10 127 4.2 30 7,708.60 3,555.79 4,152.81 1041500 ODELL THOMAS 9/18/10 10/25/10 000 .0 30 7,500.00 .00 7,500.00 3238058 ZIMMERMAN MARY MARGARET 3/12/10 3/27/10 000 .0 15 28,972.64 .00 28,972.64 3240859 PETERSON ANNA R 4/18/10 4/23/10 000 .0 5 6,150.54 .00 6,150.54 3240963 HARRIS JOE BEASLEY 4/19/10 4/26/10 000 .0 7 17,854.36 .00 17,854.36 3241045 ZIMMERMAN HENRY 4/20/10 4/24/10 000 .0 4 5,875.23 .00 5,875.23 3241069 WILLOUGHBY JOSEPH D 4/21/10 4/26/10 000 .0 5 9,492.02 .00 9,492.02 3241114 IGNAGNI ROBERT 4/21/10 4/23/10 000 .0 2 3,546.25 .00 3,546.25 3241171 FITZGERALD CHARLES D 4/23/10 4/28/10 085 4.9 5 10,405.29 4,281.69 6,123.60 3241179 WILLOUGHBY GERTRUDE 4/23/10 4/24/10 000 .0 1 2,746.22 .00 2,746.22 3241271 ROBERTSON ANNIE C 4/24/10 4/26/10 000 .0 2 2,939.68 .00 2,939.68 /\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\ 3251003 HARRIS GEORGE M 10/16/10 11/06/10 000 .0 21 5,488.25 .00 5,488.25 4251004 PARKER ALBERT DALE 10/11/10 10/11/10 464 2.5 1 277.50 649.80 372.30- 4251008 SIMMS BETTY 10/16/10 10/16/10 000 .0 1 682.40 .00 682.40 4251027 SIMMS BETTY 12/05/10 12/05/10 127 4.5 1 480.80 788.06 307.26- PAYOR/PLAN TOTALS --- PATIENT COUNT: 58 TOTALS: 560 354,828.46 9,275.34 345,553.12 PAYOR TOTALS --------- PATIENT COUNT: 58 TOTALS: 560 354,828.46 9,275.34 345,553.12


BILLED CLAIMS – SUMMARY LOGS HOSPITAL TYPE 1 HMS HOSPITAL MED003B PAGE 1 BILL CLASSIFICATION 1 ALL CLAIMS LOG SUMMARY DATE: 1/08/11 PAYOR 002 MEDICARE FROM 1/01/10 TO 12/31/10 TIME: 13:01:12 ADMISSION DATE ADMISSION --DAYS-- COVERED H B P DEDUCTIBLE NET PAYMENT OUTLIER EXPECTED CONTRACTUAL R A DATE/ DATE TOT CVD CHARGES AMOUNT & CO-PAY BENEFITS COMPUTED AMOUNT PAYMENT ADJUSTMENT R A AMOUNT PAYOR 002/001 3231019 01 COLBURN RALPH T F/C - M DRG 113 WT 2.7283 01/10/10 11/22/10 9 9 22283.79 .00 .00 22283.79 9576.77 .00 9576.77 12707.02 .00 3226453 01 EDWARDS LOUISE G F/C - M DRG 510 WT 1.3335 01/10/10 9/17/10 3 3 1694.40 .00 .00 1694.40 4680.80 .00 4680.80 2986.40- .00 3192032 01 FITZGERALD CHARLES M F/C - M DRG 154 WT 4.1847 01/10/10 4/10/99 5 5 12816.23 1179.00 .00 11637.23 14282.63 .00 14282.63 2645.40- .00 3230219 01 GAMBLE GENEVA B F/C - M DRG 073 WT .7667 01/10/10 11/10/10 1 1 2947.35 .00 .00 2947.35 2691.24 .00 2691.24 256.11 .00 1041329 02 HARRIS FRANCES E F/C - M DRG 358 WT 1.2357 01/10/10 10/12/10 9 0 462.00 462.00 .00 .00 4337.50 .00 4337.50 4337.50- .00 1040592 01 JONES EDNA O F/C - M DRG 089 WT 1.0838 01/10/10 2/22/10 4 4 4180.66 .00 .00 4180.66 3704.49 .00 3704.49 476.17 .00 /\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\ 3218854 01 ODONNELL FLOYD E F/C - M DRG 143 WT .5342 01/10/10 5/25/10 1 1 3215.84 353.70 .00 2862.14 1875.13 .00 1875.13 987.01 .00 3231847 02 ZIMMERMAN HURSHEL L F/C - M DRG 175 WT .5456 01/10/10 12/05/10 4 0 150.00 150.00 .00 .00 1915.14 .00 1915.14 1915.14- .00 3224811 02 ZIMMERMAN ORVILL C F/C - M DRG 174 WT .9933 01/10/10 8/23/10 4 0 99.00 99.00 .00 .00 3486.64 .00 3486.64 3486.64- .00 ---- ---- ------------ ---------- ---------- ------------ ------------ ---------- ------------ ----------- ------------ PLAN 001 TOTALS: 16 64 50772.77 .00 74036.42 74036.42 .00 * 23 5167.20 45605.57 .00 28430.85- 1041333 02 HARRIS LEONARD M F/C - M DRG 336 WT .8965 01/10/10 10/04/10 2 0 240.00 240.00 .00 .00 .00 .00 .00 .00 .00 ---- ---- ------------ ---------- ---------- ------------ ------------ ---------- ------------ ----------- ------------ PLAN 002 TOTALS: 1 2 240.00 .00 .00 .00 .00 * 0 240.00 .00 .00 .00 PAYOR 002 TOTALS: 17 66 51012.77 .00 74036.42 74036.42 .00 23 5407.20 45605.57 .00 28430.85-


BAD DEBT PAYOR LOG HOSPITAL TYPE 1 HMS HOSPITAL MED007 PAGE 1 BILL CLASSIFICATION 3 BAD DEBT PAYOR LOG DATE: 1/08/11 PAYOR ALL FROM 1/01/10 TO 12/31/10 TIME: 14:05:51 WRITE-OFF DATE PLAN ALL ADMIT DISCH CO- BLOOD NON- WRITE-OFF WRITE-OFF CURRENT B/D DATE DATE DEDUCTIBLE PAY DEDUCT COVERED DATE AMOUNT RECOVERY BALANCE R/A DATE F/C PAYOR 184 PLAN 001 NAME OTHER INS 3227019 ODELL SAMANTHA L FIRST CONTACT: 11/21/00 POLICY#: 409 33 3998 9/25/10 9/25/10 .00 .00 .00 .00 5/01/10 20.47 .00 20.47 0/00/00 1 ----------- ---------- ---------- ---------- ------------- ------------- ------------- PLAN TOTALS: .00 .00 20.47 20.47 PATIENTS 1 .00 .00 .00 PAYOR TOTALS: .00 .00 20.47 20.47 PATIENTS 1 .00 .00 .00 PAYOR 396 PLAN 001 UNITED HEALTHCARE 3153941 JONES DAVID FIRST CONTACT: 1/06/10 POLICY#: 6/27/10 6/27/10 ***** NO LOG FOUND ***** 5/14/10 50.00 .00 50.00 0/00/00 1 3141325 JONES NICHOLUS FIRST CONTACT: 2/12/10 POLICY#: 12/30/10 12/30/10 ***** NO LOG FOUND ***** 6/10/10 50.00 .00 50.00 0/00/00 1 ----------- ---------- ---------- ---------- ------------- ------------- ------------- PLAN TOTALS: .00 .00 100.00 100.00 PATIENTS 2 .00 .00 .00 PAYOR TOTALS: .00 .00 100.00 100.00 PATIENTS 2 .00 .00 .00 ----------- ---------- ---------- ---------- ------------- ------------- ------------- FINAL TOTALS: .00 .00 120.47 120.47 PATIENTS 3 .00 .00 .00

Contract Management File Listings Page 3.1

PAYOR PLAN FILE DATE 8/07/10 HMS HOSPITAL PAGE 1 PAYOR PLAN FILE LISTING -- DETAIL BY NUMBER PB0R0C * CO: 006 AARP ** PLAN: 001 AARP PAYOR TYPE : C ADDRESS: PO BOX 13999 PAYOR PLAN TYPE : 4 POLICY #: PAYOR NAME CD: PRINT UB92 : Y DETAIL LAB/UB92: N PHILADELPHIA PA GROUP #: E/B PLAN CD : 000 PRINT 1500 : 3 LIC#-UPIN#/UB92: 19187-0216 GROUP NM: CYCLE BILL DY: 00 1500 BY DR : 1 PRIMARY F/C: C (800) 523-5800 UB92 PROVIDER: 1500 PROVIDER: EDIT 72 HR RULE: N EDIT MED NEC: N PRICE CD I/P: 1 AUTO CONTRACTUAL: N CONTRACTUAL TRANS CD: 000 NON-COVERED UB92 CDS: PRICE CD O/P: 1 PSRO APPROVAL : N TREATMENT AUTH REQ : N UB92 CODE : 1 DIAGNOSIS REQ : Y COORDINATION BENEFIT: Y ASC CODE : N PROC CODE METHOD: I SPECIAL BILL FORM : 0 LOG PLAN : Y PROVIDER TYPE CD: COMBINE MOTHER/BABY : N PRORATE PLAN : N CHECK INSURANCE ELIGIBILITY FLAG : ELIGIBILITY VENDOR : TYPE COVERAGE: 3 COST BASED 01 PER DIEM DEDUCTIBLE: .00 CO-PAY TYPE CO-PAY AMOUNT: .00 CO-PAY PERCENT: 0 PER DIEM AMOUNT: 50.00 PERCENT: .00 * CO: 017 BLUE CROSS/BLUE SHIELD ** PLAN: 040 BC/BS OF TN/RBS CLINIC PAYOR TYPE : B ADDRESS: 801 PINE STREET PAYOR PLAN TYPE : 4 POLICY #: PAYOR NAME CD: PRINT UB92 : N DETAIL LAB/UB92: N CHATTANOOGA TN GROUP #: E/B PLAN CD : 000 PRINT 1500 : 3 LIC#-UPIN#/UB92: 37402 GROUP NM: RBS CLINIC CYCLE BILL DY: 00 1500 BY DR : 1 PRIMARY F/C: B (000) 000-0000 UB92 PROVIDER: 3064077 1500 PROVIDER: 3064077 EDIT 72 HR RULE: N EDIT MED NEC: N PRICE CD I/P: 1 AUTO CONTRACTUAL: N CONTRACTUAL TRANS CD: 000 NON-COVERED UB92 CDS: PRICE CD O/P: 1 PSRO APPROVAL : N TREATMENT AUTH REQ : N UB92 CODE : 1 DIAGNOSIS REQ : Y COORDINATION BENEFIT: Y ASC CODE : N PROC CODE METHOD: I SPECIAL BILL FORM : 0 LOG PLAN : Y PROVIDER TYPE CD: COMBINE MOTHER/BABY : N PRORATE PLAN : N CHECK INSURANCE ELIGIBILITY FLAG : ELIGIBILITY VENDOR : TYPE COVERAGE: 1 BASIC BENEFITS DEDUCTIBLE: .00 .00 $/DAY FOR 0 DAYS .00 %/DAY FOR 0 DAYS 1500 BILLING INFORMATION PAYOR.. 017 PAY PLAN: 040 HSV: RBS FACILITY NAME: FRANK RUTHERFORD MEM HOSP DBA RBS RURAL CLINIC FACILITY ADDRESS: P O BOX 319 FACILITY CITY/STATE: CARTHAGE TN FACILITY ZIP CODE: 370300319 PRINT NAME & ADDRESS: Y PRINT NAME/ADDR RIGHT OR LEFT: R LOC 24 I/P: 21 O/P: 11 LOC 24K BLANK: Y LOC 24K PHY NAME/#: N LOC 29 AMOUNT PAID: PHY AUTHORIZED REP: MAMOGRAPHY CERTIFICATION#: N LOC 33 SUPPLIER/ADDR: N LOC 33 PHY/ADDR/PROV#: Y


CONTRACT HEADER LISTING 08/07/10 14:23:56 CONTRACT HEADER INFORMATION PAGE 1 Contract Contract Start Expire Original Date Stop/Loss Number Name Date Date Date Basis Code 10 ALASKA FUND ONE 2010-04-02 2011-04-02 2010-04-02 A 102 100 DEVOID CTY SCHOOLS 2009-09-01 2010-09-01 2009-09-01 D 102 100 DEVOID CTY SCHOOLS 2009-09-01 2011-09-01 2009-09-01 D 101 200 CITY OF NASHVILLE 2010-01-01 2011-01-01 2010-01-01 D 101 2,002 TARGET EMPLOYEES UNI 2010-01-01 2011-12-31 2010-05-20 D 0


CONTRACT DETAIL LISTING 08/07/10 14:23:57 CONTRACT DETAIL LISTING PAGE 1 Contract Contract Start Expire Seq Cat# Category Form# Formula Number Name Date Date Name Name 10 ALASKA FUND ONE 2003-04-02 2011-04-02 10 275 CARDIAC PROCEDURES 2 PER CASE 20 125 CCHS PROGRAM ONE 1 PER DIEM 100 DEVOID CTY SCHOOLS 1999-09-01 2010-09-01 10 100 ASC 17 ASC PAYMENT GROUP 10 100 ASC 17 ASC PAYMENT GROUP 20 200 ASC EXCLUDED 3 PERCENT 20 200 ASC EXCLUDED 3 PERCENT 300 800 C-SECTION 20 REVENUE CODE SET 300 800 C-SECTION 20 REVENUE CODE SET 400 700 NORMAL DELIVERY 20 REVENUE CODE SET 400 700 NORMAL DELIVERY 20 REVENUE CODE SET 500 400 IP ALL 3 PERCENT 500 400 IP ALL 3 PERCENT 100 DEVOID CTY SCHOOLS 2001-09-01 2010-09-01 10 100 ASC 17 ASC PAYMENT GROUP 10 100 ASC 17 ASC PAYMENT GROUP 20 200 ASC EXCLUDED 3 PERCENT 20 200 ASC EXCLUDED 3 PERCENT 30 300 OP ALL 3 PERCENT 30 300 OP ALL 3 PERCENT 300 800 C-SECTION 20 REVENUE CODE SET 300 800 C-SECTION 20 REVENUE CODE SET 400 700 NORMAL DELIVERY 5 PERCENT/REVENUE CODE 400 700 NORMAL DELIVERY 5 PERCENT/REVENUE CODE 500 400 IP ALL 3 PERCENT 500 400 IP ALL 3 PERCENT 200 CITY OF NASHVILLE 2001-01-01 2011-01-01 100 275 CARDIAC PROCEDURES 40 CHARGE CODE SET 150 800 C-SECTION 20 REVENUE CODE SET 175 400 IP ALL 25 DRG FILE 200 1,100 OP RAD THERAPY 35 FEE SCHEDULE 300 1,000 OP PSY ADULT 1 PER DIEM 310 300 OP ALL 17 ASC PAYMENT GROUP 2,002 TARGET EMPLOYEES UNI 2002-01-01 2012-12-31 5 800 C-SECTION 3 PERCENT 10 101 OBSTETRICS 1 PER DIEM 30 400 IP ALL 20 REVENUE CODE SET 70 350 OBSERVATION PATIENTS 1 PER DIEM 80 300 OP ALL 17 ASC PAYMENT GROUP 300 1,100 OP RAD THERAPY 35 FEE SCHEDULE 400 250 EMERGENCY 20 REVENUE CODE SET 500 125 CCHS PROGRAM ONE 14 PER QUANTITY


CONTRACT CATEGORY LISTING PA0R45 HMS HOSPITAL PAGE: 1 HOSPITAL: 001 MONITOR CM CATEGORY LISTING DATE: 08/07/10 TIME: 14:23:58 CODE DESCRIPTION CALCULATION ---- ----------- ----------- 100 ASC HOSPITAL SERVICE CODE HSSVC = 'ASC' 101 OBSTETRICS HOSPITAL SERVICE CODE HSSVC = 'OIP' 250 EMERGENCY Patient Type of Service IDCDE = 'E' Patient Type of Service HSSVC = 'ERS' 275 CARDIAC PROCEDURES DRG DRG BETWEEN 104 AND 107 300 OP ALL HOSPITAL SERVICE CODE HSSVC IN ('E','R') 350 OBSERVATION PATIENTS Patient Type of Service IDCDE = 'OBS' 400 IP ALL HOSPITAL SERVICE CODE HSSVC = 'I' 405 EMERGENCY <21 YRS Patient Type of Service IDCDE = 'E' Patient Type of Service HSSVC = 'ERS' Patient Type of Service AGE < 21 Patient Type of Service SEX = 'F' 425 IP SURGICAL REVENUE CODE INSCD BETWEEN 360 AND 369 REVENUE CODE IDCDE = 'I' 600 CARDIOVASCULAR PROC DRG DRG BETWEEN 104 AND 112 700 NORMAL DELIVERY DRG DRG BETWEEN 372 AND 375 800 C-SECTION DRG DRG IN (370,371) DRG DRG BETWEEN 1 AND 468 900 OP CT SCAN Patient Type of Service IDCDE IN ('E','R','O') Patient Type of Service INSCD BETWEEN 350 AND 359 1000 OP PSY ADULT REVENUE CODE INSCD IN (912,915) REVENUE CODE AGE >= 18 AGE >= 18 1100 OP RAD THERAPY Patient Type of Service IDCDE IN ('E','O','R') Patient Type of Service INSCD IN (333,335)


STOP / LOSS LISTING

08/07/10 14:23:59 STOP/LOSS LISTING PAGE 1 Contract Contract Contract Contract Stop/Loss Amount Percent Flat Number Start Date End Date Name Formula Amount 10 2010-04-02 2011-04-02 ALASKA FUND ONE 102 .00 .000 70,000.00 100 2009-09-01 2010-09-01 DEVOID CTY SCHOOLS 102 50,000.00 .700 .00 102 50,000.00 .700 .00 100 2010-09-01 2011-09-01 DEVOID CTY SCHOOLS 102 50,000.00 .700 .00 102 50,000.00 .700 .00 200 2010-01-01 2011-01-01 CITY OF NASHVILLE 101 65,000.00 .500 .00


REVENUE SET LISTING 08/07/10 14:24:00 REVENUE SET LISTING PAGE 1 Cont# Contract Start Expire Cat# Category Revenue Rev Tier For Trim Cont Maximum Name Date Date Name Desc Cde Cde Pt Rate 10 ALASKA FUND ONE 2010-04-02 2011-04-02 400 IP ALL BLOOD ADMINISTRATION 391 1 .50 EMERGENCY ROOM 450 1 2 200.00 100 DEVOID CTY SCHOOLS 2009-09-01 2010-09-01 700 NORMAL DELIVERY ROOM-BOARD/OB 112 1 1 1 900.00 112 1 1 1 900.00 112 2 1 999 450.00 112 2 1 999 450.00 100 DEVOID CTY SCHOOLS 2009-09-01 2010-09-01 800 C-SECTION ROOM-BOARD/PVT 110 1 2 3 2950.00 110 1 2 3 2950.00 110 2 1 999 875.00 110 2 1 999 875.00 ROOM-BOARD/SEMI 120 1 2 3 2750.00 120 1 2 3 2750.00 120 2 1 999 820.00 120 2 1 999 820.00 100 DEVOID CTY SCHOOLS 2010-09-01 2011-09-01 700 NORMAL DELIVERY ROOM-BOARD/OB 112 1 1 1 900.00 112 1 1 1 900.00 112 2 1 999 450.00 112 2 1 999 450.00 100 DEVOID CTY SCHOOLS 2010-09-01 2011-09-01 800 C-SECTION ROOM-BOARD/PVT 110 1 2 3 2950.00 110 1 2 3 2950.00 110 2 1 999 875.00 110 2 1 999 875.00 ROOM-BOARD/SEMI 120 1 2 3 2750.00 120 1 2 3 2750.00 120 2 1 999 820.00 120 2 1 999 820.00 200 CITY OF NASHVILLE 2010-01-01 2011-01-01 275 CARDIAC PROCEDURES CT SCAN 350 14 1 1200.00 ROOM-BOARD/SEMI 120 1 2 3 500.00 120 2 2 999 525.00 200 CITY OF NASHVILLE 2010-01-01 2011-01-01 400 IP ALL ROOM-BOARD/SEMI 120 1 2 3 1200.00 120 2 1 999 450.00 200 CITY OF NASHVILLE 2010-01-01 2011-01-01 *** OP PSY ADULT R/B SEMI-DETOX 126 1 2 3 1500.00 126 2 1 999 350.00 **** TARGET EMPLOYEES UNI 2011-01-01 2012-12-31 125 CCHS PROGRAM ONE ROOM-BOARD/SEMI 120 1 2 3 1200.00 120 2 1 999 425.00 30000 **** TARGET EMPLOYEES UNI 2011-01-01 2012-12-31 300 OP ALL ROOM-BOARD/SEMI 120 1 2 3 2000.00


ASC PAYMENT GROUP LISTING 08/07/10 14:24:01 ASC PAYMENT GROUP PAGE 1 Cont# Contract Start Expire Payment Payment Payment Payment Payment Payment Payment Payment Payment Name Date Date Rate 1 Rate 2 Rate 3 Rate 4 Rate 5 Rate 6 Rate 7 Rate 8 Rate 9 10 ALASKA FUND ONE 2010-01-01 2011-12-31 767.00 1025.00 1178.00 1392.00 1656.00 2080.00 2296.00 2418.00 10 ALASKA FUND ONE 2010-06-01 2013-12-31 767.00 1025.00 1178.00 1392.00 1656.00 2080.00 2296.00 2418.00 100 DEVOID CTY SCHOOLS 2009-09-01 2011-09-01 767.00 1025.00 1178.00 1392.00 1656.00 2080.00 2296.00 2418.00 767.00 1025.00 1178.00 1392.00 1656.00 2080.00 2296.00 2418.00 100 DEVOID CTY SCHOOLS 2010-09-01 2013-09-01 767.00 1025.00 1178.00 1392.00 1656.00 2080.00 2296.00 2418.00 767.00 1025.00 1178.00 1392.00 1656.00 2080.00 2296.00 2418.00 200 CITY OF NASHVILLE 2010-01-01 2013-01-01 767.00 1025.00 1178.00 1392.00 1656.00 2080.00 2296.00 2418.00


DRG TERMS LISTING 08/07/10 14:29:01 MEDICARE DRG TERMS PAGE 1 Cont# Contract Start Expire DRG Low Outlier Low Outl Inlier High Outl Rate Above Name Date Date Rate Trim Pt Rate Trim Pt High Outl Trim Pt 200 CITY OF NASHVILLE 2011-01-01 2013-01-01 1 .80 0 11,768.60 0 905.28 CITY OF NASHVILLE .80 0 11,768.60 0 905.28 200 CITY OF NASHVILLE 2011-01-01 2013-01-01 2 .80 0 11,833.96 0 854.00 CITY OF NASHVILLE .80 0 11,833.96 0 854.00 200 CITY OF NASHVILLE 2011-01-01 2013-01-01 3 .80 0 7,459.02 0 411.13 CITY OF NASHVILLE .80 0 7,459.02 0 411.13 200 CITY OF NASHVILLE 2011-01-01 2013-01-01 4 .80 0 8,708.84 0 823.81 CITY OF NASHVILLE .80 0 8,708.84 0 823.81 * * * E N D O F R E P O R T * * *


CPT PROCEDURES LISTING MR0R43 HMS HOSPITAL PAGE 1 CPT CODE LISTING 8/07/10 CPT MED PMT REL SEX ANESTH APC BILAT QUEST UNLIST CODE DESCRIPTION SERV CLS UNITS CODE BS VAL STAT CODE FLAG FLAG GH DIAG MAMMO TO SCREENING MAMO 0 HB ADULT PROGRAM,NON GERIATIC HC ADULT PROGRAM, GERIATIC HF SUBSTANCE ABUSE PROGRAM TD RN TE LPN/LVN TS FOLLOW-UP SERVICE TT INDIV SERV - MULT PATIENTS TW BACK-UP EQUIPMENT U1 MEDICAID LEVEL OF CARE 1 U2 MEDICAID LEVEL OF CARE 2 AAA RUG III DEFAULT SE3 RUG III EXTENSIVE CARE SE3 HAFJ HIPPS CODE = HAFJ: HHRG = C0F1S0 HDFJ HIPPS CODE = HDFJ: HHRG = C3F1S0 A0100 NONEMERGENCY TRANSPORT TAXI E 0 3 A4556 ELECTRODES, PAIR A 0 A4557 LEAD WIRES, PAIR A 0 A4558 CONDUCTIVE PASTE OR GEL A 0 A4618 BREATHING CIRCUITS A 0 A9300 EXERCISE EQUIPMENT E 0 C1009 PLASMA,CRYOPRECIPITATE-REDUC A J 0 C1010 BLOOD, L/R, CMV-NEG A J 0 C1011 PLATELETS, HLA-M, L/R, UNIT A G 0 D0350 ORAL/FACIAL IMAGES E E 0 D0472 GROSS EXAM, PREP & REPORT E S 0 00472 ANESTH, CHEST WALL REPAIR A N 0 00474 ANESTH, SURGERY OF RIB(S) A C 0 00500 ANESTH, ESOPHAGEAL SURGERY A N 0 11401 EXC TR-EXT B9+MARG 0.6-1 CM S 1 T 0 11423 EXC H-F-NK-SP B9+MARG 2.1-3 S 1 T 0 11960 INSERT TISSUE EXPANDER(S) S 2 T 0 11970 REPLACE TISSUE EXPANDER S 3 T 0 11971 REMOVE TISSUE EXPANDER(S) 1 T 0 15840 GRAFT FOR FACE NERVE PALSY S 4 T 0 23020 RELEASE SHOULDER JOINT S 2 T 1 23030 DRAIN SHOULDER LESION S 1 T 0 85410 FIBRINOLYTIC ANTIPLASMIN L A 0 87045 FECES CULTURE, BACTERIA L A 0 87999 MICROBIOLOGY PROCEDURE L A 0 1 88000 AUTOPSY (NECROPSY), GROSS L E 0 90657 FLU VACCINE, 6-35 MO, IM X 0 90658 FLU VACCINE, 3 YRS, IM X 0 92014 EYE EXAM & TREATMENT V 2 99303 NURSING FACILITY CARE E 0 3 99311 NURSING FAC CARE, SUBSEQ E 0 3

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