{
	"reporting_entity_name": "Hometown Health",
	"reporting_entity_type": "Group Health Plan",
	"issuer_name": "Hth Scp",
	"plan_name": "HTH SENIOR CARE PLUS: HTH SENIOR CARE PLUS NORTHERN NEVADA",
	"plan_id_type": "HIOS",
	"plan_id": "10620109",
	"plan_market_type": "group",
	"last_updated_on": "2026-05-08",
	"version": "2.0.1",
	"out_of_network":[{
		"name": "HTH SN RN HH OR HSPC",
		"billing_code_type": "HCPCS",
		"billing_code_type_version": "2026",
		"billing_code": "G0299",
		"description": "Sn Rn HH or Hspc",
		"allowed_amounts":[{
			"tin": {
				"type": "ein",
				"value": "880265275"
			},
			"service_code": ["12"],
			"billing_class": "institutional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 275.00,
					"npi": [1497746226]
				}]
			}]
		}]
	},{
		"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": "203059260"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 67.04,
				"providers":[{
					"billed_charge": 202.00,
					"npi": [1326429457]
				}]
			},{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 202.00,
					"npi": [1326429457]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "263303591"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 75.68,
				"billing_code_modifier": ["25"],
				"providers":[{
					"billed_charge": 153.00,
					"npi": [1518956804]
				}]
			},{
				"allowed_amount": 75.68,
				"providers":[{
					"billed_charge": 153.00,
					"npi": [1588245716,1912439191]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "274428766"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 157.00,
					"npi": [1407936024]
				}]
			}]
		}]
	},{
		"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": "263303591"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 113.00,
				"providers":[{
					"billed_charge": 230.00,
					"npi": [1407590128,1588245716,1912439191]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "274428766"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 225.00,
					"npi": [1407936024]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "462236637"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 225.00,
					"npi": [1356521074]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "742083988"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 224.00,
					"npi": [1649246463]
				},{
					"billed_charge": 230.00,
					"npi": [1649246463]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "823362725"
			},
			"service_code": ["21"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 111.81,
				"providers":[{
					"billed_charge": 862.88,
					"npi": [1063827079,1821343922]
				}]
			},{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 862.88,
					"npi": [1821343922,1992447585]
				}]
			}]
		}]
	}]
}
