{
	"reporting_entity_name": "Hometown Health",
	"reporting_entity_type": "Group Health Plan",
	"issuer_name": "HTH Nevada Department of Corrections",
	"plan_name": "HOMETOWN NEVADA DEPARTMENT OF CORRECTIONS: TPA NEVADA DEPARTMENT OF CORRECTIONS",
	"plan_id_type": "HIOS",
	"plan_id": "80000119",
	"plan_market_type": "group",
	"last_updated_on": "2026-04-08",
	"version": "2.0.1",
	"out_of_network":[{
		"name": "PR SUBSEQUENT HOSPITAL CARE,LEVL II",
		"billing_code_type": "CPT",
		"billing_code_type_version": "2026",
		"billing_code": "99232",
		"description": "Subsequent Hospital Care,Levl II",
		"allowed_amounts":[{
			"tin": {
				"type": "ein",
				"value": "263668328"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 225.00,
					"npi": [1083856710,1457091407,1477202802,1568083376,1598394876,1669009742,1992379531]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "333790977"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 187.65,
					"npi": [1528018587]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "815094291"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 278.00,
					"npi": [1396468344,1811420672,1962152454]
				},{
					"billed_charge": 292.00,
					"npi": [1396468344]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "882677486"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 113.52,
					"npi": [1013236405]
				}]
			}]
		}]
	},{
		"name": "PB SUBSEQUENT HOSPITAL CARE,LEVL III",
		"billing_code_type": "CPT",
		"billing_code_type_version": "2026",
		"billing_code": "99233",
		"description": "Subsequent Hospital Care,Levl III",
		"allowed_amounts":[{
			"tin": {
				"type": "ein",
				"value": "010868234"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 318.60,
					"npi": [1558914218]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "260755054"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 1023.39,
					"npi": [1477075893]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "262875532"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 276.00,
					"npi": [1265480479]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "263668328"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"billing_code_modifier": ["25"],
				"providers":[{
					"billed_charge": 320.00,
					"npi": [1104487768,1891161162]
				}]
			},{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 320.00,
					"npi": [1083241178,1457091407,1477202802,1598394876,1992379531]
				}]
			},{
				"allowed_amount": 0.00,
				"billing_code_modifier": ["GC", "25"],
				"providers":[{
					"billed_charge": 320.00,
					"npi": [1891161162]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "333790977"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 280.18,
					"npi": [1528018587]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "813419791"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"billing_code_modifier": ["GC"],
				"providers":[{
					"billed_charge": 360.00,
					"npi": [1508328675]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "815094291"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 398.00,
					"npi": [1396468344]
				},{
					"billed_charge": 418.00,
					"npi": [1396468344]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "824990723"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 405.00,
					"npi": [1033990536,1760246227]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "882677486"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 169.50,
					"npi": [1013236405]
				}]
			}]
		}]
	}]
}