{
	"reporting_entity_name": "Hometown Health",
	"reporting_entity_type": "Group Health Plan",
	"issuer_name": "HTH Providers - EPO",
	"plan_name": "HOMETOWN HEALTH PROVIDERS - EPO: Hometown Health Providers - EPO",
	"plan_id_type": "HIOS",
	"plan_id": "5800357",
	"plan_market_type": "individual",
	"last_updated_on": "2026-08-08",
	"version": "2.0.1",
	"out_of_network":[{
		"name": "PR TARGETED CASE MANAGEMENT",
		"billing_code_type": "HCPCS",
		"billing_code_type_version": "2026",
		"billing_code": "T1017",
		"description": "Targeted Case Management",
		"allowed_amounts":[{
			"tin": {
				"type": "ein",
				"value": "886000022"
			},
			"service_code": ["11", "12", "99"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"billing_code_modifier": ["HA", "HI"],
				"providers":[{
					"billed_charge": 18.76,
					"npi": [1952408239]
				},{
					"billed_charge": 37.52,
					"npi": [1952408239]
				},{
					"billed_charge": 56.28,
					"npi": [1952408239]
				},{
					"billed_charge": 75.04,
					"npi": [1952408239]
				},{
					"billed_charge": 93.80,
					"npi": [1952408239]
				}]
			}]
		}]
	}]
}