{"reporting_entity_name":"Centene Management Company LLC","reporting_entity_type":"Third Party Administrator","version":"2.0.0","last_updated_on":"2026-06-01","out_of_network":[{"name":"BREAST TOMOSYNTHESIS BI","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"77063","description":"SCREENING DIGITAL BREAST TOMOSYNTHESIS, BILATERAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY P","allowed_amounts":[{"tin":{"type":"ein","value":"933980800"},"service_code":["22"],"billing_class":"professional","payments":[{"allowed_amount":82.92,"providers":[{"billed_charge":192.00,"npi":[1447478524]}]}]}]},{"name":"PSTAY/GROUP RX","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"915","description":"PSYCHIATRIC/PSYCHOLOGICAL SERVICES - GROUP THERAPY","allowed_amounts":[{"tin":{"type":"ein","value":"233044421"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":6249.54,"providers":[{"billed_charge":10850.00,"npi":[1942273552]}]}]}]},{"name":"OFFICE/OUTPATIENT VISIT EST","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"99214","description":"OFFICE OR OTH OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH RE","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["22"],"billing_class":"professional","payments":[{"allowed_amount":117.82,"providers":[{"billed_charge":200.00,"npi":[1234567893]}]}]}]},{"name":"AMB SERVICE BLS EMERGENCY TR","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"A0429","description":"AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS, EMERGENCY)","allowed_amounts":[{"tin":{"type":"ein","value":"510176414"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":8130.10,"providers":[{"billed_charge":22000.00,"npi":[1225924616]}]}]}]}]}