{"reporting_entity_name":"Centene Management Company LLC","reporting_entity_type":"Third Party Administrator","version":"1.0.0","last_updated_on":"2025-09-02","out_of_network":[{"name":"GRND MLGE PER STATUTE MILE","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"A0425","description":"GROUND MILEAGE, PER STATUTE MILE","allowed_amounts":[{"tin":{"type":"ein","value":"931641861"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":1228.63,"providers":[{"billed_charge":7060.20,"npi":[1386337657]}]}]},{"tin":{"type":"ein","value":"610709589"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":22.02,"providers":[{"billed_charge":34.66,"npi":[1427007368]}]}]},{"tin":{"type":"ein","value":"610858140"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":479.82,"providers":[{"billed_charge":805.00,"npi":[1508823857]}]}]}]},{"name":"AMB SVC ALS ER TRNSPRT LVL1","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"A0427","description":"AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)","allowed_amounts":[{"tin":{"type":"ein","value":"610858140"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":782.06,"providers":[{"billed_charge":1690.00,"npi":[1508823857]}]}]}]},{"name":"INFUS SET EXT INSULIN PUMP","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"A4230","description":"INFUSION SET FOR EXTERNAL INSULIN PUMP, NONNEEDLE CANNULA TYPE","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":822.80,"providers":[{"billed_charge":1445.00,"npi":[1234567893]}]}]}]},{"name":"SYRINGE NDLE EXT INSULIN PUM","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"A4232","description":"SYRINGE WITH NEEDLE FOR EXTERNAL INSULIN PUMP, STERILE, 3 CC","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":398.75,"providers":[{"billed_charge":797.50,"npi":[1234567893]}]}]}]},{"name":"TUBING W/INTGR HEAT ELEM W/P","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"A4604","description":"TUBING WITH INTEGRATED HEATING ELEMENT FOR USE WITH POSITIVE AIRWAY PRESSURE DEVICE","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":790.16,"providers":[{"billed_charge":2630.48,"npi":[1234567893]}]}]}]},{"name":"FULL FCE MASK POS ARWAY PRSS","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"A7030","description":"FULL FACE MASK USED WITH POSITIVE AIRWAY PRESSURE DEVICE, EACH","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":116.85,"providers":[{"billed_charge":669.00,"npi":[1234567893]}]}]}]},{"name":"FCE MASK INTERFCE REPL FULL","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"A7031","description":"FACE MASK INTERFACE, REPLACEMENT FOR FULL FACE MASK, EACH","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":129.66,"providers":[{"billed_charge":834.00,"npi":[1234567893]}]}]}]},{"name":"HEADGEAR USED W/POS ARWAY PR","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"A7035","description":"HEADGEAR USED WITH POSITIVE AIRWAY PRESSURE DEVICE","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":150.36,"providers":[{"billed_charge":705.20,"npi":[1234567893]}]}]}]},{"name":"FLTR DISPBL W/POS ARWAY PRSS","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"A7038","description":"FILTER, DISPOSABLE, USED WITH POSITIVE AIRWAY PRESSURE DEVICE","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":267.59,"providers":[{"billed_charge":685.76,"npi":[1234567893]}]}]}]},{"name":"WATR CHAMB HUMDIFIR USED W/P","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"A7046","description":"WATER CHAMBER FOR HUMIDIFIER, USED WITH POSITIVE AIRWAY PRESSURE DEVICE, REPLACEMENT, EACH","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":24.18,"providers":[{"billed_charge":187.00,"npi":[1234567893]}]}]}]},{"name":"SENSOR; INVSV INTRSTL GLU MO","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"A9276","description":"SENSOR; INVASIVE (E.G., SUBCUTANEOUS), DISPOSABLE, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONI","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":4715.20,"providers":[{"billed_charge":6315.00,"npi":[1234567893]}]}]}]},{"name":"HUMDIFIR HEAT USED W/POS ARW","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"E0562","description":"HUMIDIFIER, HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":1262.23,"providers":[{"billed_charge":5408.15,"npi":[1234567893]}]}]}]},{"name":"CONTINUOUS POS AIRWAY PRESSU","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"E0601","description":"CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) DEVICE","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":1052.70,"providers":[{"billed_charge":19243.84,"npi":[1234567893]}]}]}]},{"name":"O2 CONC 85%/>02 CONC PRSC FL","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"E1390","description":"OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCEN","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":200.00,"providers":[{"billed_charge":1520.96,"npi":[1234567893]}]}]}]},{"name":"NEG PRSS WND TX PUMP STATN","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"E2402","description":"NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":15536.30,"providers":[{"billed_charge":48376.90,"npi":[1234567893]}]}]}]},{"name":"PROSTATE CANCER SCREENING","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"G0103","description":"PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA)","allowed_amounts":[{"tin":{"type":"ein","value":"610445850"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":3243.60,"providers":[{"billed_charge":9268.80,"npi":[1811154388]}]}]}]},{"name":"HIV ANTIGEN/ANTIBODY, COMBIN","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"G0475","description":"HIV ANTIGEN/ANTIBODY, COMBINATION ASSAY, SCREENING","allowed_amounts":[{"tin":{"type":"ein","value":"610445850"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":1516.95,"providers":[{"billed_charge":4334.40,"npi":[1811154388]}]}]}]},{"name":"VISIT CPLX INHERENT E&M ASSO","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"G2211","description":"VISIT CPLX INHERENT E&M ASSOC WITH MED CARE SRVC","allowed_amounts":[{"tin":{"type":"ein","value":"611276316"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":122.78,"providers":[{"billed_charge":336.00,"npi":[1588257133]}]},{"allowed_amount":58.32,"providers":[{"billed_charge":144.00,"npi":[1952399669]}]}]},{"tin":{"type":"ein","value":"461507241"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":88.97,"providers":[{"billed_charge":280.00,"npi":[1881738169]}]}]}]},{"name":"WRST HND ORTHOS CNTRL COCK-U","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"L3908","description":"WRIST HAND ORTHOSIS, WRIST EXTENSION CONTROL COCK-UP, NON MOLDED, PREFABRICATED, OFF-THE-SHELF","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":221.25,"providers":[{"billed_charge":354.70,"npi":[1234567893]}]}]}]},{"name":"WALKING BOOT, PNEUMATIC AND/","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"L4361","description":"WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, P","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":6661.80,"providers":[{"billed_charge":10051.20,"npi":[1234567893]}]}]}]},{"name":"HIT IMPLANTED PUMP PAIN MGMT","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"S9328","description":"HOME INFUSION THERAPY, IMPLANTED PUMP PAIN MANAGEMENT INFUSION; ADMINISTRATIVE SERVICES, PROFESSIONA","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":396.00,"providers":[{"billed_charge":1320.00,"npi":[1234567893]}]}]}]}]}