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At a Glance:
Title:
454-12-1961-m4
Date:
June 24, 2019

454-12-1961-m4

June 24, 2019

DECISION AND ORDER

I. INTRODUCTION

Various hospitals (Providers) requested hearings on decisions by the Medical Review Division (MRD) of the Texas Department of Insurance, Division of Workers’ Compensation (Division)[1] denying additional reimbursement to Providers under the Stop-Loss Exception for a hospital stay provided to an injured worker. Providers argued that reimbursement for the admission should be based on the Stop-Loss Exception to the per diem reimbursement methodology contained in the 1997 Acute Care Inpatient Hospital Fee Guideline (1997 ACIHFG).[2] By Order dated October 31, 2014, the Stop-Loss Exception cases involving the two Vista hospitals, Vista Medical Center Hospital/Surgical Specialty Hospital of America and Vista Hospital of Dallas (Vista), listed in Attachment A, were consolidated for hearing and decision under Consolidated SOAH Docket No. 454-12-1961.M4 (Lead Docket). The Lead Docket cases went to hearing in February 2016. Also set forth in Attachment A to this Order are pending non-Vista Stop‑Loss cases joined by Order dated April 14, 2014 for a common Decision and Order. By Order dated March 26, 2015, the Lead Docket was joined with the non-Vista Stop-Loss cases for a common Decision and Order (collectively, Joined Cases). The Administrative Law Judges (ALJs) find the Stop-Loss Exception should be followed in the cases set forth in Attachment 1 to this Decision and Order (Decision). For the cases set forth in Attachment 2, the ALJs find that no additional reimbursement is owed Provider. For the cases set forth in Attachment 3, the ALJs find the Stop-Loss Exception does not apply but that additional reimbursement is owed Provider. The cases set forth in Attachment 4 are rehabilitation and trauma cases to be reimbursed under a fair and reasonable standard. They are referred to Henry D. Card, the State Office of Administrative Hearings (SOAH) Economic Team Leader, for hearing.[3]

In each of the cases, Providers filed a request for dispute resolution with MRD. The MRD issued its Medical Fee Dispute Resolution Findings and Decision (MRD Decision) for each case. Providers timely requested a contested case hearing at SOAH in each of the cases. In certain of the cases, the responsible workers’ compensation insurers or self-insureds (Carrier) also filed a request for contested case hearing following issuance of the MRD Decision.

Adequate and timely notice of each hearing was provided as required. A number of SOAH ALJs presided over the hearings, presiding either individually or in various combinations. Both Providers and Carriers were represented by attorneys. The record for the cases on Attachments 1, 2, and 3 closed on June 5, 2019, following additional requests for status reports on continued/abated cases.

II. APPLICABLE LAW

Workers’ compensation insurance in Texas covers all medically necessary health care, which includes all reasonable medical aid, examinations, treatments, diagnoses, evaluations, and services reasonably required by the nature of the compensable injury and reasonably intended to cure or relieve the effects naturally resulting from a compensable injury. It includes procedures designed to promote recovery or to enhance the injured worker’s ability to return to or retain employment.[4] Title 5, subtitle A, chapters 401 through 419 of the Texas Labor Code constitute the Texas Workers’ Compensation Act (Act).

Act § 413.011 provides that the Division by rule shall establish medical policies and guidelines relating to fees charged or paid for medical services for employees who suffer compensable injuries, including guidelines relating to payment of fees for specific medical treatments or services. That section further provides that fee guidelines must befair and reasonableand designed to ensure the quality of medical care and to achieve effective medical cost control.[5]

Moreover, the guidelines may not provide for payment of a fee in excess of the fee charged for similar treatment of an injured individual of an equivalent standard of living and paid by that individual or by someone acting on that individual’s behalf.[6] In setting such guidelines, the increased security of payment afforded by the Act must be considered.[7]

The 1997 ACIHFG governed the reimbursement that workers’ compensation carriers paid hospitals for qualified inpatients with admissions dates commencing August 1, 1997,[8]and prior to March 1, 2008.[9] As previously noted, the 1997 ACIHFG generally reimbursed hospitals according to a per diem methodology.[10] The per diem rate was intended to cover all inpatient services provided to the injured worker. However, so long as the “bills do not reach the stop-loss threshold,” in addition to the standard per diem rate, a hospital could recover reimbursement in addition to the standard per diem.[11] Implantables (revenue codes 275, 276, and 278), and orthotics and prosthetics (revenue code 274) were to be reimbursed at the hospital’s cost plus 10%.[12] Pharmaceuticals administered during the admission charged at greater than $250 per dose were reimbursed at the hospital’s cost plus 10%.[13] The following services were to be reimbursed at “a fair and reasonable rate:” (1) Magnetic Resonance Imaging (MRI) (revenue codes 610-619);[14] (2) Computerized Axial Tomography (CAT scans) (revenue codes 350-352, and 359);[15] (3) Hyperbaric oxygen (revenue code 413);[16] (4) Blood (revenue codes 380-399);[17] and (5) Air ambulance (revenue code 545).[18]

Certain types of admissions were exempted from the per diem methodology based upon their ICD-9 Codes.[19] The following admissions were reimbursed at a fair and reasonable rate: (1) Trauma (ICD-9 codes 800.0-959.50); Burns (ICD-9 codes 940-949.9); and Human Immunodeficiency Virus (HIV) (ICD-9 codes 042-044.9).

The purpose of the Stop-Loss Methodology is “to ensure fair and reasonable compensation to the hospital for unusually costly services rendered during treatment to an injured worker.”[20] For the Stop-Loss Exception to apply, a hospital’s total post-audit charges must exceed $40,000, the minimum stop-loss threshold (Stop-Loss Threshold).[21] Hospitals were required to bill their usual and customary charges.[22] Thus, a hospital’s post-audit usual and customary charges for the admission, including items listed in Former Rule 134.401(c)(4), are used to calculate whether the Stop-Loss Threshold has been met for a workers’ compensation admission. According to Former Rule 134.401(c)(6)(A)(3), “[i]f audited charges exceed the Stop-Loss Threshold, reimbursement for the entire admission shall be paid using a Stop-Loss Reimbursement Factor (SLRF) of 75%.” Thus, when the Stop-Loss Methodology applies to a workers’ compensation hospitalization, all eligible items, including items listed in Former Rule 134.401(c)(4), are reimbursed at 75% of their post-audit charges.

The application of the Stop-Loss Exception and the meaning of Former Rule 134.401(c)(6)(A)(3), was the subject of intense and protracted litigation. The history of the legal debate is well-described in Vista Medical Center Hospital v. Texas Mutual Insurance Co., 416 S.W.3d 11, 18-20 (Tex. App.—Austin 2013, no pet.) (op. on reh’g). The interpretation of the Former Rule and the application of the Stop-Loss Exception were somewhat resolved in Texas Mutual Insurance Co. v. Vista Community Medical Center, LLP, 275 S.W.3d 538 (Tex. App.—Austin 2008, pet. denied) (Vista I). In Vista I, the Court held that in addition to showing that the charges from the admission met the Stop-Loss Threshold, the hospitals were also required to show that “the admission involved unusually costly and unusually extensive services to receive reimbursement under the Stop-Loss method.”[23]

The unresolved portion of the multi-prong Stop-Loss Exception is defining “unusually costly and unusually extensive.” “What is unusually costly and unusually extensive in any particular fee dispute remains a fact-intensive inquiry best left to the Division’s determination on a case-by-case basis.”[24] The court also stated that the two phrases are sufficiently definite to provide guidance to the Division and to the “ALJs who review and determine medical fee disputes on a case-by case basis.”[25]

III. DISCUSSION

The insurance carriers and hospitals have proffered various theories as to the interpretation of the phrase “unusually costly” services. Two proposals used comparisons with several variables: (1) measuring a hospital’s billed charges and its payments received by diagnosis and procedure against the relevant averages to determine whether the charges and/or payments fall under, at, or above, the statewide average; or (2) using hospital cost to charge ratio(s) calculated by the Centers for Medicare and Medicaid Services (CMS) for each hospital on an annual basis for the Medicare cost report and then comparing the cost, using either an average cost-to-charge ratio (single ratio methodology) or a traditional departmental cost-to-charge ratio methodology, of a specific admission against the hospital average admission, average workers’ compensation admission, etc. Four other proposals used bright-line comparisons: (1) determining whether the admission was assigned to a Medicare DRG[26] with a relative weight greater than 1.6 or some other number; (2) determining whether the admission was assigned to a DRG with a relative weight greater than the unweighted average of some Medicare case mix indices; (3) determining whether the principal procedure in the admission was performed in 9% or fewer of all workers’ compensation admissions in that year; or (4) determining whether the admission, had it been covered by Medicare, would have qualified for Medicare outlier payment using cost-to-charge ratios from the hospital’s Medicare cost report. Mindful of the emphasis that Vista I placed on a case‑by‑case decision on the application of the Stop-Loss Exception, the ALJs respectfully decline to adopt any of the bright-line tests proffered. Thus, there is no need to analyze any of the bright-line tests further.

With respect to whether the services provided by the hospital were “unusually extensive,” Vista I also makes clear the determination is a fact-intensive inquiry made on a case-by-case basis.[27] Carriers generally contend the correct comparison is between either identical or similar surgical procedures while Providers generally proposed a comparison to a mix of procedures.

Once the ALJs determined the post-audit billed charges for a qualifying admission met the Stop-Loss Threshold, the ALJs proceeded with the two-part analysis required under Vista I. For the unusually costly services determination, the ALJs concluded it was appropriate and helpful, as an initial cost analysis, to compare the hospital’s costs for the admission using the CMS[28] departmental cost-to-charge ratios methodology for the departments covered by the per diem reimbursement (Per Diem Services) against the per diem reimbursement for that admission. If the hospital’s costs for Per Diem Services are covered by the per diem reimbursement, then no further analysis is required. If the hospital’s costs for Per Diem Services are not covered by the per diem reimbursement, then a second analysis may be required.

The second analysis attempts to determine why the hospital’s costs for Per Diem Services were not covered by the per diem reimbursement. The second analysis examines the Per Diem Services provided to the injured worker during the admission and considers the injured worker’s prior medical history, condition and medical events at the time of admission through time of surgery, the surgery and medical events during surgery, and post-operative condition and post‑operative medical events until time of discharge. While the need and scope of consulting specialists is a factor in determining “unusually extensive,” the associated professional fees are not considered in determining “unusually costly” because the associated professional fees are not costs absorbed by the hospital. If the second analysis determined that the Per Diem Services provided to treat the injured worker were unusually extensive, then the ALJs applied the Stop-Loss Exception to all post-audit billed charges. If the second analysis determined that the Per Diem Services provided to treat the injured worker were not unusually extensive, the reimbursement deficiency may simply reflect that the per diem reimbursement was inadequate for reasons either outside the scope of the hearing or due to insufficient cost reimbursement evidence.

There are adjustments to Provider reimbursement even when the Stop-Loss Exception does not apply. As the ALJs examined the reimbursement disputes on a case-by-case basis, they attempted to address some deficiencies in implant reimbursement calculations and some calculation errors. For some Per Diem Services, additional reimbursement could not be determined because of insufficient evidence. In some cases, the Carrier sought a refund of some portion of the reimbursement paid to a Provider. In each of those cases, the ALJs agreed with the Division that the Carrier failed to comply with the applicable regulatory requirements. Moreover, in each of those cases the credible evidence in the record failed to prove that the payment made to the Provider violated the Act.

In support of these determinations, the ALJs make the following findings of fact and conclusions of law.

IV. FINDINGS OF FACT

  1. On various dates between 1997 through 2008, various hospitals (Providers) provided inpatient hospital services to injured workers in the cases listed on Attachments 1, 2, 3, and 4.
  2. The carriers or self-insureds (Carriers) specified on Attachment A were the responsible workers’ compensation insurers for the respective injured workers.
  3. Providers billed the respective Carriers for the services they provided to the injured worker in each case.
  4. The responsible Carrier reimbursed the Provider the amount specified in the column denominated “Carrier Payment” for the services provided to the injured worker in each case.
  5. Carriers were required to reimburse Providers under the Texas Department of Insurance, Division of Workers’ Compensation’s (Division) Acute Care Inpatient Hospital Fee Guideline (1997 ACIHFG).
  6. The 1997 ACIHFG generally reimbursed hospitals according to a per diem methodology (Fee Rule).
  7. Providers requested additional reimbursement in each case under the Stop‑Loss Exception to the Fee Rule. The Stop-Loss Exception, 28 Texas Administrative Code § 134.401(c)(2)(c), when it applies, provides for payment by the insurer in the amount of 75% of the hospital’s audited billed charges.
  8. Renaissance Hospitals is in a Chapter 7 bankruptcy proceeding. Pursuant to an August 2010 Bankruptcy Court Order, the automatic stay was lifted to allow the Chapter 7 Bankruptcy Trustee for Renaissance Hospitals to continue the claims adjudication process regarding workers’ compensation receivables on behalf of the debtor’s estate.
  9. All cases listed on Attachments 1, 2, and 3 involve billed charges greater than $40,000, one of the three requirements for application of the Stop-Loss Exception. In each case, the Division separately identified and analyzed the following additional issues to determine whether the admission qualified for the Stop-Loss Exception: (1) whether the admission involved unusually extensive hospital services, and (2) whether the admission involved unusually costly hospital services.
  10. Providers timely filed requests for medical fee dispute resolution with the Division.
  11. The Division issued a Medical Fee Dispute Resolution Findings and Decision (MRD Decision) in each case.
  12. In each case, the Division found that the admissions in dispute were not eligible for reimbursement under the Stop-Loss Exception and should be calculated pursuant to the Fee Rule –– 28 Texas Administrative Code § 134.401(c)(1), entitled “Standard Per Diem Amount,” and §134.401(c)(4), entitled “Additional Reimbursements.”
  13. In certain of the cases, the Division ordered Carriers to pay additional reimbursement to Providers.
  14. In certain of the cases, the Division determined the reimbursement owed Providers was less than the Carriers paid Providers.
  15. The Division almost never possessed all of the documentation needed to fully calculate the total reimbursement owed under the per diem methodology.
  16. Providers timely requested hearings before the State Office of Administrative Hearings (SOAH) to contest the MRD Decisions in these cases.
  17. By Order dated October 31, 2014, the Stop-Loss Exception cases involving the two Vista hospitals, Vista Medical Center Hospital/Surgical Specialty Hospital of America and Vista Hospital of Dallas (Vista), were consolidated for hearing and decision under Consolidated SOAH Docket No. 454-12-1961.M4 (Lead Docket).
  18. Non-Vista Stop-Loss cases were joined by Order dated April 14, 2014, for a common Decision and Order.
  19. By Order dated March 26, 2015, the Lead Docket was joined with the non-Vista Stop-Loss cases joined by previous order for a common Decision and Order.
  20. All parties were informed of the date, time, and location of the hearing; the matters to be considered; the legal authority under which the hearing would be held; and the statutory provisions applicable to the matters to be considered.
  21. The hearing on the merits in the Lead Docket was convened at SOAH in Austin, Texas, on February 23 and 24, 2016, before a five‑judge panel consisting of Administrative Law Judges Howard S. Seitzman, Gary W. Elkins, Michael J. O’Malley, Steven M. Rivas, and Pratibha J. Shenoy. All parties were represented by counsel. The non-Vista Stop-Loss cases were heard on various dates or were submitted by agreement for decision based upon written submissions, including the pre-filed evidence. All parties were represented by counsel. The record for the cases on Attachments 1, 2, and 3 closed on June 5, 2019.
  22. Providers proposed specific categorical approaches to determining what constituted unusually extensive and unusually costly hospital services.
  23. Cases received after a certain date and cases for which no responsible representative could be determined (Orphan Cases) were excluded from the hearing docket and remain pending at SOAH for further proceedings.
  24. Certain of the cases initially included in the Lead Docket and the non-Vista Stop-Loss docket involved types of admissions exempted from the per diem methodology based upon their ICD-9 Codes. The following admissions are reimbursed at a fair and reasonable rate: (1) Trauma (ICD-9 codes 800.0-959.50); Burns (ICD-9 codes 940-949.9); and Human Immunodeficiency Virus (HIV) (ICD-9 codes 042-044.9).
  25. For the cases set forth in Attachment 1, the preponderance of the credible evidence in the record shows the inpatient hospital stay qualifies for the Stop-Loss Exception to the per diem methodology and that additional reimbursement is owed to Provider by the respective Carrier.
  26. For the cases set forth in Attachment 2, the preponderance of the credible evidence in the record shows the inpatient hospital stay does not qualify for the Stop-Loss Exception to the per diem methodology and that no additional reimbursement is owed to Provider by the respective Carrier.
  27. For the cases set forth in Attachment 3, the preponderance of the credible evidence in the record shows the inpatient hospital stay does not qualify for the Stop-Loss Exception to the per diem methodology but that additional reimbursement is owed to Provider by the respective Carrier.
  28. For the cases set forth in Attachment 4, the preponderance of the credible evidence in the record shows the inpatient hospital admission is exempted from the per diem methodology based upon the ICD-9 Codes, either (1) Trauma (ICD-9 codes 800.0-959.50); (2) Burns (ICD-9 codes 940-949.9); or (3) Human Immunodeficiency Virus (HIV) (ICD-9 codes 042-044.9), and are to be reimbursed at a fair and reasonable rate.
  29. In each of the cases in which Carrier sought a refund of any of the reimbursement paid to Provider, the preponderance of the credible evidence in the record fails to show that Carrier complied with the applicable regulatory requirements for seeking and obtaining a refund.
  30. In each of the cases in which Carrier sought a refund of any of the reimbursement paid to Provider, the preponderance of the credible evidence in the record fails to prove that the payment made to Provider violated the Act.

V. CONCLUSIONS OF LAW

  1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order. Tex. Lab. Code § 413.031; Tex. Gov’t Code ch. 2003.
  2. Adequate and timely notice of the hearing was provided as required. Tex. Gov’t Code §§ 2001.051, .052.
  3. The 1997 ACIHFG governed the reimbursement that workers’ compensation carriers paid hospitals for qualified inpatients with admissions dates commencing August 1, 1997, and prior to March 1, 2008.
  4. The 1997 ACIHFG, originally codified at 28 Texas Administrative Code § 134.401 (Former Rule), established a general reimbursement scheme for all inpatient services provided by an acute care hospital for medical and/or surgical admissions using a service‑related standard per diem amount. Independent reimbursement is allowed on a case-by-case basis if the particular case exceeds the Stop-Loss Threshold as described in paragraph (6) of Former Rule 134.401(c). This independent reimbursement mechanism, the Stop-Loss Method or Stop-Loss Methodology, is sometimes referred to as the Stop‑Loss Exception or the Stop-Loss Rule.
  5. The Stop-Loss Exception requires a hospital to demonstrate that the hospital services it provided were both “unusually extensive” and “unusually costly.” Texas Mutual Insurance Co. v. Vista Community Medical Center, LLP., 275 SW 3d 538 (Tex. App.—Austin 2008, pet. denied).
  6. Whether the hospital provided unusually extensive and unusually costly services is a fact‑intensive inquiry that is determined on a case‑by‑case basis. Texas Mutual Insurance Co. v. Vista Community Medical Center, LLP., 275 SW 3d 538 (Tex. App.—Austin 2008, pet. denied).
  7. For the cases set forth in Attachment 1, the preponderance of the credible evidence in the record shows the inpatient hospital stay qualifies for the Stop-Loss Exception to the per diem methodology and that additional reimbursement is owed to Provider by the respective Carrier.
  8. For the cases set forth in Attachment 2, the preponderance of the credible evidence in the record shows the inpatient hospital stay does not qualify for the Stop-Loss Exception to the per diem methodology and that no additional reimbursement is owed to Provider by the respective Carrier.
  9. For the cases set forth in Attachment 3, the preponderance of the credible evidence in the record shows the inpatient hospital stay does not qualify for the Stop-Loss Exception to the per diem methodology but that additional reimbursement is owed to Provider by the respective Carrier.
  10. For the cases set forth in Attachment 4, the preponderance of the credible evidence in the record shows the inpatient hospital admission is exempted from the per diem methodology based upon the ICD-9 Codes, and is to be reimbursed at a fair and reasonable rate.
  11. For the cases set forth in Attachment 4, additional proceedings will be needed to determine a fair and reasonable reimbursement amount.
  12. For the cases set forth in Attachments 1, 2, and 3, Carriers are not entitled to refunds for any of the reimbursement paid to Providers.
  13. In each of the cases in which Carrier sought a refund of any of the reimbursement paid to Provider, the preponderance of the credible evidence in the record fails to prove that the payment made to Provider violated the Act.
  14. For the cases listed on Attachments 1 and 3, Carriers should be ordered to make the additional reimbursement payments as set forth in the column denominated “Additional Reimbursement Owed to Provider.”

ORDER

IT IS ORDERED that the respective Carriers shall make payments to the respective Providers as set forth on Attachment 1 and 3 to this Decision and Order, together with all interest as required by law. IT IS FURTHER ORDERED that no additional reimbursement is owed to Providers by the respective Carriers for the cases set forth in Attachment 2 to this Decision and Order. IT IS FURTHER ORDERED thatCarriers receive no refunds for any reimbursement paid to Providers in the cases set forth in Attachments 1, 2, and 3 to this Decision and Order. IT IS FURTHER ORDERED that the cases set forth in Attachment 4 to this Decision and Order are SEVERED from these Joined and Consolidated dockets andassigned toAdministrative Law Judge HDC, SOAH Economic Team Leader, for further proceedings as to a fair and reasonable reimbursement amount. All relief not expressly granted herein is expressly DENIED.

Signed June 24, 2019.

ATTACHMENT A (03-25-2015) Stop-Loss

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-1389.M4

06-4838

Corpus Christi Medical Center

Texas Mutual Insurance Co.

454-13-1806.M4

07-2097

Clear Lake Regional Medical Center

Texas Mutual Insurance Co.

454-13-1807.M4

07-7244

Corpus Christi Medical Center

Texas Mutual Insurance Co.

454-13-1818.M4

06-2572

Rio Grande Regional Hospital

Texas Mutual Insurance Co.

454-13-1858.M4

07-5853

Texas Orthopedic Hospital

Texas Mutual Insurance Co.

454-13-1875.M4

07-2005

Rio Grande Regional Hospital

Texas Mutual Insurance Co.

454-13-2595.M4

07-5061

Texas Orthopedic Hospital

Texas Mutual Insurance Co.

454-13-3425.M4

08-1539

Corpus Christi Medical Center

Texas Mutual Insurance Co.

454-13-3436.M4

07-5962

Corpus Christi Medical Center

Texas Mutual Insurance Co.

454-13-3464.M4

06-7434

Corpus Christi Medical Center

Texas Mutual Insurance Co.

454-13-3466.M4

08-6413

Texas Orthopedic Hospital

Texas Mutual Insurance Co.

454-13-3467.M4

07-5070

Texas Orthopedic Hospital

Texas Mutual Insurance Co.

454-13-3472.M4

06-7049

Corpus Christi Medical Center

Texas Mutual Insurance Co.

ATTACHMENT A (03-25-2015) Stop-Loss

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-1788.M4

06-2835

Texas Orthopedic Hospital

Indiana Lumbermens Mutual

454-13-1850.M4

06-3621

Corpus Christi Medical Center

Zurich American Insurance Co.

454-13-1851.M4

06-6520

Texas Orthopedic Hospital

Old Republic Insurance Co.

454-13-1852.M4

05-6931

Texas Orthopedic Hospital

Zurich American Insurance Co.

454-13-1853.M4

08-7019

Corpus Christi Medical Center

Facility Insurance Corp.

454-13-1854.M4

08-3458

Texas Orthopedic Hospital

American Zurich Insurance Co.

454-13-1855.M4

08-2999

Texas Orthopedic Hospital

TML Axia Services

454-13-1856.M4

08-2041

Texas Orthopedic Hospital

Texas Municipal League Intergovernmental Risk Pool

454-13-1878.M4

09-0050

Corpus Christi Medical Center

Bradford Holding Co., Inc.

454-13-1879.M4

09-0049

Corpus Christi Medical Center

Bradford Holding Co., Inc.

454-13-2591.M4

08-4746

Kingwood Medical Center

United States Fire Ins. Co.

454-13-2606.M4

05-B502

Corpus Christi Medical Center

American Home Assurance Co.

454-13-3440.M4

08-7132

Texas Orthopedic Hospital

East Tx Educational Ins. Assoc.

454-13-3545.M4

07-5944

Texas Orthopedic Hospital

Connecticut Indemnity Co.

454-13-3547.M4

06-6830

Texas Orthopedic Hospital

Gray Insurance Co.

454-13-3548.M4

08-5240

Texas Orthopedic Hospital

Texas Municipal League Intergovernmental Risk Pool

454-13-3560.M4

07-3678

Texas Orthopedic Hospital

Metropolitan Transit Authority

454-13-4188.M4

06-4514

Texas Orthopedic Hospital

Insurance Co. of the State of PA

ATTACHMENT A (CONTINUED) (03-25-2015) Stop-Loss

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-4189.M4

07-0920

Texas Orthopedic Hospital

New Hampshire Insurance Co.

454-13-4190.M4

05-2742

Corpus Christi Medical Center

Kiewit Corporation

454-13-4195.M4

08-2226

Kingwood Medical Center

Indemnity Insurance Co. of North America

454-13-4329.M4

05-6894

Texas Orthopedic Hospital

TPS Joint Self Insurance Funds

454-13-4632.M4

07-5963

Spring Branch Medical Center

Ace American Insurance Co.

454-13-4633.M4

07-7231

Texas Orthopedic Hospital

Fidelity & Guaranty Insurance Co.

454-13-4700.M4

08-6310

Corpus Christi Medical Center

Bradford Holding Co., Inc.

ATTACHMENT A (03-25-2015) Stop-Loss

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-1804.M4

07-1386

Christus St. John Hospital

Texas Mutual Insurance Co.

454-13-3422.M4

09-0147

Christus St. John Hospital

Texas Mutual Insurance Co.

454-13-3471.M4

07-4384

Christus St. Elizabeth Hospital

Texas Municipal League Intergovernmental Risk Pool

454-13-3559.M4

08-2269

Christus St. Elizabeth Hospital

East TX Educational Ins. Assoc.

454-13-4196.M4

07-4526

Christus St. Elizabeth Hospital

Insurance Co. of the State of PA

454-13-4328.M4

06-2199

Christus St. Joseph Hospital

Continental Western Insurance Co.

454-13-4634.M4

07-6458

Christus St. Elizabeth Hospital

Dolgencorp of Texas, Inc.

ATTACHMENT A (03-25-2015) Stop-Loss

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-12-0785.M4

04-6842

Spring Branch Medical Center

Texas Mutual Insurance Co.

454-13-1265.M4

04-A430

Spring Branch Medical Center

Texas Mutual Insurance Co.

454-13-1805.M4

06-6439

Spring Branch Medical Center

Texas Mutual Insurance Co.

454-13-3424.M4

04-A432

Texas Orthopedic Hospital

Texas Mutual Insurance Co.

ATTACHMENT A (03-25-2015) Stop-Loss

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-0988.M4

09-8055

Sierra Medical Center

Texas Mutual Insurance Co.

454-13-2530.M4

08-7184

Encino Medical Center

Texas Mutual Insurance Co.

454-13-2957.M4

05-1635

RHD Memorial Medical Center

Texas Mutual Insurance Co.

454-13-2965.M4

09-2649

Sierra Medical Center

Texas Mutual Insurance Co.

454-13-2528.M4

08-5290

Houston Northwest Medical Center

American Home Assurance Co.

454-13-2527.M4

09-2100

Centennial Medical Center

Insurance Co. of the State of PA

454-13-2963.M4

09-2681

Providence Memorial Hospital

Facility Insurance Corp.

454-13-2967.M4

08-0921

RHD Memorial Medical Center

Zurich American Insurance Co.

454-13-5958.M4

08-4321

Centennial Medical Center

Zurich American Insurance Co.

ATTACHMENT A (03-25-2015) Stop-Loss

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-1270.M4

06-5742

Twelve Oaks Medical Center

State Office of Risk Management

454-13-1271.M4

05-6242

Twelve Oaks Medical Center

State Office of Risk Management

454-13-1272.M4

06-0183

Twelve Oaks Medical Center

State Office of Risk Management

454-13-1874.M4

06-5355

Corpus Christi Medical Center

State Office of Risk Management

454-13-2610.M4

08-0380

Texas Orthopedic Hospital

State Office of Risk Management

454-13-3468.M4

07-1690

Twelve Oaks Medical Center

State Office of Risk Management

454-13-3469.M4

08-7134

Texas Orthopedic Hospital

State Office of Risk Management

454-13-3470.M4

07-8012

Texas Orthopedic Hospital

State Office of Risk Management

454-13-3764.M4

06-7165

Twelve Oaks Medical Center

State Office of Risk Management

454-13-4701.M4

07-1731

Texas Orthopedic Hospital

State Office of Risk Management

ATTACHMENT A (03-25-2014) Stop-Loss

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-12-7500.M4

05-A362

Corpus Christi Medical Center

Liberty Mutual Fire Ins. Co.

454-12-7510.M4

06-4720

HCA Mainland Medical Center

Liberty Mutual Ins. Co.

454-12-7513.M4

05-0798

Liberty Mutual Ins. Co. (Josey)

HCA Spring Branch Medical Center

454-12-7515.M4

05-3904

Liberty Mutual Ins. Co. (Josey)

HCA Spring Branch Medical Center

454-13-1841.M4

08-6350

Bayshore Medical Center

Texas Association of Counties RMP

454-13-1842.M4

07-3139

Corpus Christi Medical Center

Liberty Mutual Fire Ins. Co.

454-13-1843.M4

07-3761

Twelve Oaks Medical Center

Wausau Business Insurance Co.

454-13-1845.M4

08-2554

Triumph Hospital San Angelo

Lumbermens Mutual Casualty Co.

454-13-2607.M4

09-1348

Triumph Hospital El Paso

Liberty Insurance Corporation

454-13-3551.M4

07-4555

Christus St. Elizabeth Hospital

Liberty Insurance Corporation

454-13-3552.M4

07-3599

Texas Orthopedic Hospital

Liberty Mutual Ins. Co.

454-13-4192.M4

09-3479

Christus St. Elizabeth Hospital

Liberty Mutual Ins. Co.

454-13-4193.M4

05-1926

Spring Branch Medical Center

Liberty Mutual Ins. Co.

454-13-4318.M4

07-0672

Twelve Oaks Medical Center

Netherlands Insurance Co.

454-13-4330.M4

06-6523

Christus St. Joseph Hospital

Liberty Mutual Fire Ins. Co.

454-13-4641.M4

06-7044

Texas Orthopedic Hospital

Liberty Mutual Fire Ins. Co.

454-13-4642.M4

08-2140

West Houston Medical Center

Liberty Mutual Ins. Co.

454-13-4643.M4

05-3214

Corpus Christi Medical Center

Liberty Mutual Fire Ins. Co.

454-13-4647.M4

06-7763

Austin Surgical Hospital

Liberty Mutual Ins. Co.

454-13-4695.M4

08-5593

Christus St. John Hospital

Pacific Employers Insurance Co.

ATTACHMENT A (03-25-2015) CONTINUED Stop-Loss

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-4698.M4

06-5764

Texas Orthopedic Hospital

Liberty Insurance Corporation

454-13-4706.M4

08-4751

Texas Orthopedic Hospital

Liberty Insurance Corporation

454-13-4762.M4

04-7903

Spring Branch Medical Center

Liberty Mutual Fire Ins. Co.

454-13-4763.M4

09-6007

Corpus Christi Medical Center

Liberty Insurance Corporation

ATTACHMENT A (03-25-2015) Stop-Loss

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-12-0520.M4

04-2761

HCA Spring Branch Medical Center

TPCIGA for Reliance National

454-12-7453.M4

06-3096

Twelve Oaks Medical Center

Continental Cas. Co.

454-12-7498.M4

05-B550

Transportation Insurance Co.

HCA Conroe Regional Medical Center

454-12-7499.M4

06-2756

Texas Orthopedic Hospital

TASB Risk Management Fund

454-12-7503.M4

06-0636

Twelve Oaks Medical Center

Mid-Century Ins. Co.

454-12-7504.M4

05-5765

Twelve Oaks Medical Center

TPCIGA for Reliance National

454-12-7508.M4

06-1375

Corpus Christi Medical Center

West Texas Educational Insurance/Alice ISD

454-12-7511.M4

05-1928

Mid-Century Ins. Co.

HCA Spring Branch Medical Center

454-12-7512.M4

04-1493

Truck Insurance Exchange

HCA Spring Branch Medical Center

454-12-7710.M4

05-5106

American Home Assurance Co.

Texas Orthopedic Hospital

454-12-7730.M4

04-B464

TPCIGA for Paula Ins. Co.

Valley Regional Medical Center

454-12-7744.M4

04-9796

TPCIGA for Petrosurance Casualty Co.

Rio Grande Regional Hospital

454-12-7746.M4

05-0303

TPCIGA for Colonial Casualty Insurance Co.

HCA Spring Branch Medical Center

454-13-1268.M4

05-9198

Spring Branch Medical Center

Am. Cas. Co. of Reading, PA

454-13-1274.M4

07-1249

Texas Orthopedic Hospital

Transcontinental Insurance Co.

454-13-1384.M4

05-A343

Spring Branch Medical Center

Continental Cas. Co.

454-13-1494.M4

07-5069

TPCIGA for Reliance National

Twelve Oaks Medical Center

ATTACHMENT A (03-25-2015) CONTINUED Stop-Loss

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-1759.M4

07-1104

TPCIGA for Home Insurance Co.

Twelve Oaks Medical Center

454-13-1764.M4

08-6253

Employers Assurance Co.

Texas Orthopedic Hospital

454-13-1789.M4

06-1935

Twelve Oaks Medical Center

Truck Insurance Exchange

454-13-1798.M4

06-1691

Twelve Oaks Medical Center

TPCIGA for Home Indemnity Co.

454-13-1813.M4

05-9361

Twelve Oaks Medical Center

Am. Cas. Co. of Reading, PA

454-13-1844.M4

07-4938

Corpus Christi Medical Center

National American Insurance Co.

454-13-1846.M4

07-5069

Twelve Oaks Medical Center

TPCIGA for Reliance National

454-13-1887.M4

08-2555

Texas Orthopedic Hospital

TPCIGA for Paula Ins. Co.

454-13-1888.M4

07-0578

Corpus Christi Medical Center

Am. Cas. Co. of Reading, PA

454-13-2526.M4

07-1395

Twelve Oaks Medical Center

Am. Cas. Co. of Reading, PA

454-13-2960.M4

05-4435

Twelve Oaks Medical Center

TPCIGA for Colonial Casualty Insurance Co.

454-13-2971.M4

07-3266

Twelve Oaks Medical Center

Hartford Underwriters Insurance Co.

454-13-3407.M4

07-0181

Twelve Oaks Medical Center

TPCIGA for Casualty Reciprocal

454-13-3435.M4

06-3826

Corpus Christi Medical Center

TASB Risk Management Fund

454-13-3439.M4

08-6253

Texas Orthopedic Hospital

Employers Assurance Co.

454-13-3460.M4

08-2040

Spring Branch Medical Center

TASB Risk Management Fund

454-13-3462.M4

07-0906

Twelve Oaks Medical Center

TASB Risk Management Fund

454-13-3554.M4

07-1852

Twelve Oaks Medical Center

Aberdeen Ins. Co.

454-13-3555.M4

07-2414

Rio Grande Regional Hospital

Employers Assurance Co.

ATTACHMENT A (03-25-2015) CONTINUED Stop-Loss

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-3556.M4

07-0973

Twelve Oaks Medical Center

National Fire Insurance

454-13-3558.M4

07-1104

Twelve Oaks Medical Center

TPCIGA for Home Insurance Co.

454-13-3766.M4

06-7477

Twelve Oaks Medical Center

Am. Cas. Co. of Reading, PA

454-13-3800.M4

08-0332

Texas Orthopedic Hospital

Hartford Insurance Co. of the Midwest

454-13-3805.M4

07-5509

Corpus Christi Medical Center

National American Insurance Co.

454-13-4194.M4

05-5106

Texas Orthopedic Hospital

American Home Assurance Co.

454-13-4637.M4

06-6838

Petroleum Casualty Co.

Texas Orthopedic Hospital

454-13-4697.M4

08-2284

Texas Orthopedic Hospital

TPCIGA for Reliance National Insurance)

454-13-5585.M4

06-6838

Texas Orthopedic Hospital

Petroleum Casualty Co.

454-13-1267.M4

05-A363

Spring Branch Medical Center

TPCIGA for Am. Motorists Ins. Co.

ABATED

454-13-1273.M4

05-9933

Twelve Oaks Medical Center

TPCIGA for American Manufacturers Mutual Ins.

ABATED

454-13-4316.M4

07-2924

Twelve Oaks Medical Center

TPCIGA for American Manufacturers Mutual Ins.

ABATED

454-13-4692.M4

07-0288

Twelve Oaks Medical Center

TPCIGA for Lumbermens Mutual Casualty Co.

ABATED

454-13-4708.M4

07-0752

Twelve Oaks Medical Center

TPCIGA for Lumbermens Mutual Casualty Co.

ABATED

454-13-4709.M4

06-6598

Twelve Oaks Medical Center

TPCIGA for Lumbermens Mutual Casualty Co.

ABATED

ATTACHMENT A (03-25-2015) Stop-Loss

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-4181.M4

07-6050

Valley Regional Medical Center

West American Insurance Co.

ATTACHMENT A (03-25-2015) Stop-Loss

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-3798.M4

05-4612

Renaissance Hospital

Insurance Co. of the State of PA

454-13-3803.M4

07-7937

Renaissance Hospital

Assurance Co. of America

454-13-3942.M4

08-4649

Renaissance Hospital

Facility Insurance Corp.

454-13-4019.M4

07-3229

Renaissance Hospital

Zurich American Insurance Co.

454-13-4029.M4

09-2859

Renaissance Hospital

TPS Joint Self Insurance Funds

454-13-4153.M4

08-0968

Renaissance Hospital

Old Republic Insurance Co.

454-13-4156.M4

08-1419

Renaissance Hospital

Zurich American Insurance Co.

454-13-5234.M4

08-1628

Renaissance Hospital

American Zurich Insurance Co.

454-13-5237.M4

07-0732

Renaissance Hospital

American Zurich Insurance Co.

454-13-5238.M4

09-0032

Renaissance Hospital

Fire & Casualty Insurance Co.of Connecticut

ATTACHMENT A (03-25-2015) Stop-Loss

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-2529.M4

07-6767

Houston Northwest Medical Center

Liberty Insurance Corporation

454-13-2596.M4

09-2165

Centennial Medical Center

Liberty Mutual Fire Ins. Co.

454-13-2597.M4

09-3854

Houston Northwest Medical Center

Liberty Insurance Corporation

454-13-2954.M4

09-0203

Providence Memorial Hospital

Liberty Insurance Corporation

454-13-2956.M4

09-2863

Providence Memorial Hospital

Liberty Mutual Ins. Co.

454-13-3950.M4

08-4685

Park Plaza Hospital

Liberty Insurance Corporation

454-13-4166.M4

07-4267

Trinity Medical Center

Liberty Mutual Ins. Co.

454-13-5957.M4

07-4250

Trinity Medical Center

Liberty Mutual Fire Insurance Co.

ATTACHMENT A (03-25-2015) Stop-Loss

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-1106.M4

07-4485

Park Plaza Hospital

Hartford Underwriters Insurance Co.

454-13-2600.M4

09-3868

Centennial Medical Center

Hartford Casualty Insurance Co.

454-13-2969.M4

06-6108

Sierra Medical Center

Hartford Casualty Insurance Co.

ATTACHMENT A Vista Consolidated Stop-Loss Cases

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-1548.M4

06-3132

Vista Medical Center Hospital

North Forest ISD

454-13-2183.M4

07-4277

Vista Medical Center Hospital

Houston ISD

454-13-4582.M4

04-6097

Vista Medical Center Hospital

Harris Health System

454-13-0083.M4

04-0292

Vista Medical Center Hospital

Houston ISD

ATTACHMENT A Vista Consolidated Stop-Loss Cases

Part 1 of 2

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-0141.M4

06-2077

Texas Mutual Insurance Co.

Vista Hospital of Dallas

454-13-0143.M4

06-2270

Texas Mutual Insurance Co.

Vista Medical Center Hospital

454-13-0417.M4

06-2270

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-0419.M4

06-2077

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-0420.M4

03-9053

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-0898.M4

05-A922

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-0899.M4

05-8001

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-0989.M4

08-1759

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-1538.M4

07-8171

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-1544.M4

06-5864

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-1547.M4

06-2300

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-1550.M4

07-2560

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-1605.M4

07-4568

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-2126.M4

07-0571

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-2127.M4

06-5194

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-2135.M4

07-7746

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-2188.M4

07-3964

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-2427.M4

07-7060

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-2430.M4

06-3550

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-2443.M4

07-1614

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-2445.M4

07-4045

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-2450.M4

07-7352

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-2538.M4

07-0709

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-2774.M4

08-0634

Surgery Specialty Hospital of America

Texas Mutual Insurance Co.

454-13-2776.M4

07-4976

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-3300.M4

08-4499

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-3303.M4

08-6241

Surgery Specialty Hospital of America SE Houston Campus

Texas Mutual Insurance Co.

454-13-3306.M4

07-5511

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-3307.M4

08-6160

Surgery Specialty Hospital of America SE Houston Campus

Texas Mutual Insurance Co.

454-13-3309.M4

06-7626

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-3312.M4

07-5191

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-3327.M4

06-7727

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-3334.M4

06-6823

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-3689.M4

06-5224

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-3691.M4

07-0727

Vista Medical Center Hospital

Texas Mutual Insurance Co.

ATTACHMENT A Vista Consolidated Stop-Loss Cases

Part 2 of 2

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-3694.M4

05-4551

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-4259.M4

07-5293

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-4381.M4

04-1080

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-4384.M4

07-3987

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-4386.M4

07-0576

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-4440.M4

07-4038

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-4444.M4

07-5512

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-4459.M4

08-4997

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-4461.M4

08-6154

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-4463.M4

09-3486

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-4568.M4

05-8002

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-13-4583.M4

03-9085

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-5035.M4

04-5349

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-13-5055.M4

06-2396

Vista Hospital of Dallas

Texas Mutual Insurance Co.

454-14-2857.M4

14-1734

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-14-2861.M4

14-1733

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-15-1335.M4

06-2223

Vista Medical Center Hospital

Texas Mutual Insurance Co.

454-15-1336.M4

05-6409

Vista Hospital of Dallas

Texas Mutual Insurance Co.

ATTACHMENT A Vista Consolidated Stop-Loss Cases

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-14-2085.M4

06-3910

Vista Medical Center Hospital

Louisiana Pacific Corporation

ATTACHMENT A Vista Consolidated Stop-Loss Cases

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-2140.M4

07-2209

Vista Hospital of Dallas

American Home Assurance Co.

454-13-3305.M4

07-5593

Vista Medical Center Hospital

American Home Assurance Co.

454-13-3321.M4

08-5502

Surgery Specialty Hospital of America SE Houston Campus

American Home Assurance Co.

454-13-3685.M4

09-5185

Vista Hospital of Dallas

American Home Assurance Co.

454-13-4278.M4

09-5344

Surgery Specialty Hospital of America

American Home Assurance Co.

ATTACHMENT A Vista Consolidated Stop-Loss Cases

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-1534.M4

07-3237

Vista Hospital of Dallas

ABF Freight System, Inc.

ATTACHMENT A Vista Consolidated Stop-Loss Cases

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-0604.M4

07-1490

Vista Medical Center Hospital

Texas Department of Transportation

454-13-2415.M4

06-6524

Vista Medical Center Hospital

Texas Department of Transportation

ATTACHMENT A Vista Consolidated Stop-Loss Cases

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-2187.M4

05-4763

Vista Medical Center Hospital

State Office of Risk Management

454-13-2456.M4

06-5284

Vista Hospital of Dallas

State Office of Risk Management

454-13-2465.M4

07-1518

Vista Hospital of Dallas

State Office of Risk Management

454-13-5181.M4

06-3938

Vista Medical Center Hospital

State Office of Risk Management

ATTACHMENT A Vista Consolidated Stop-Loss Cases

Part 1 of 3

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-12-7446.M4

06-1464

Vista Medical Center Hospital

Twin City Fire Insurance Co.

454-12-7449.M4

06-2240

Vista Medical Center Hospital

Continental Cas. Co.

454-12-7450.M4

06-2391

Vista Hospital of Dallas

Valley Forge Insurance Co.

454-12-7451.M4

06-2625

Vista Medical Center Hospital

Continental Cas. Co.

454-12-7452.M4

06-2973

Vista Hospital of Dallas

Continental Cas. Co.

454-12-7497.M4

06-0376

Vista Medical Center Hospital

Benchmark Insurance Co.

454-12-7501.M4

05-B626

Vista Medical Center Hospital

Transportation Insurance Co.

454-12-7502.M4

06-1568

Vista Medical Center Hospital

Mid-Century Ins. Co.

454-12-7505.M4

04-7872

Texas Hospital Insurance Exchange

Vista Medical Center Hospital

454-12-7514.M4

04-6524

Aberdeen Insur. Com

Vista Medical Center Hospital

454-12-7518.M4

05-2655

Twin City Fire Insurance Co.

Vista Medical Center Hospital

454-12-7709.M4

04-4839

Valley Forge Insurance Co.

Vista Medical Center Hospital

454-12-7711.M4

04-1629

Zenith Insurance Co.

Vista Medical Center Hospital

454-12-7713.M4

04-B490

Hartford Casualty Insurance Co.

Vista Medical Center Hospital

454-12-7716.M4

04-7849

Hartford Underwriters Insurance Co.

Vista Medical Center Hospital

454-12-7717.M4

03-A580

Twin City Fire Insurance Co.

Vista Medical Center Hospital

454-12-7728.M4

03-7954

TPCIGA for Reliance National Ins.

Vista Medical Center Hospital

454-12-7729.M4

03-8985

TPCIGA for Reliance National Ins.

Vista Medical Center Hospital

454-12-7731.M4

04-4031

TPCIGA for Reliance National Ins.

Vista Medical Center Hospital

454-12-7732.M4

04-3841

Mid-Century Ins. Co.

Vista Medical Center Hospital

454-12-7733.M4

05-6933

TPCIGA for United Pacific Ins. Co.

Vista Medical Center Hospital

454-12-7734.M4

04-6514

TPCIGA for Credit Genera Indem.

Vista Medical Center Hospital

454-12-7735.M4

04-7821

TPCIGA for Reliance National Ins.

Vista Medical Center Hospital

454-12-7736.M4

04-6054

TPCIGA for United Pacific Ins. Co.

Vista Medical Center Hospital

454-12-7738.M4

04-5607

TPCIGA for United Pacific Ins. Co.

Vista Medical Center Hospital

454-12-7740.M4

04-6048

Highland Insurance Co.

Vista Medical Center Hospital

454-12-7741.M4

04-5352

TPCIGA for Petrosurance Cas. Co.

Vista Medical Center Hospital

454-12-7742.M4

03-2228

TPCIGA for Petrosurance Cas. Co.

Vista Medical Center Hospital

454-12-7743.M4

03-1728

TPCIGA for United Pacific Ins. Co.

Vista Medical Center Hospital

454-12-7745.M4

05-1477

TPCIGA for Reliance National

Vista Medical Center Hospital

454-12-7747.M4

04-3359

TPCIGA for Reliance National

Vista Medical Center Hospital

454-12-7957.M4

04-3770

Valley Forge Insurance Co.

Vista Medical Center Hospital

454-12-7958.M4

03-3974

TPCIGA for Reliance National Ins.

Vista Medical Center Hospital

454-12-7959.M4

04-5383

Transcontinental Insurance Co.

Vista Medical Center Hospital

454-12-7960.M4

03-5820

Continental Cas. Co.

Vista Medical Center Hospital

454-12-7961.M4

04-2253

Am. Cas. Co. of Reading, PA

Vista Medical Center Hospital

454-12-7962.M4

04-6388

TPCIGA for Reliance National Ins.

Vista Medical Center Hospital

454-12-7963.M4

04-3351

TPCIGA for Legion Insurance Co.

Vista Medical Center Hospital

ATTACHMENT A Vista Consolidated Stop-Loss Cases

Part 2 of 3

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-12-7964.M4

05-3457

TPCIGA for Home Indemnity Co.

Vista Medical Center Hospital

454-12-7965.M4

03-8491

TPCIGA for Legion Insurance Co.

Vista Medical Center Hospital

454-13-0983.M4

07-7015

Vista Medical Center Hospital

TPCIGA for Freestone Ins. fka Dallas Nat. Ins. Co.

454-13-1118.M4

05-5193

Vista Hospital of Dallas

Transportation Insurance Co.

454-13-1119.M4

05-B619

Vista Hospital of Dallas

TPCIGA for Legion Insurance Co.

454-13-1120.M4

04-7834

Vista Medical Center Hospital

Twin City Fire Insurance Co.

454-13-1122.M4

06-2142

Vista Hospital of Dallas

Hartford Underwriters Insurance Co.

454-13-1124.M4

06-7709

Vista Hospital of Dallas

Nat’l Fire Ins. Co. of Hartford

454-13-1254.M4

07-4131

Vista Medical Center Hospital

ACIG Insurance Co.

454-13-1333.M4

06-5196

Vista Hospital of Dallas

Am. Cas. Co. of Reading, PA

454-13-1364.M4

08-6244

Surgery Specialty Hospital of America SE Houston Campus

Twin City Fire Insurance Co.

454-13-1367.M4

07-4009

Vista Medical Center Hospital

TPCIGA for Petrosurance Cas. Co.

454-13-2138.M4

07-1482

Vista Hospital of Dallas

TPCIGA for Freestone Ins. fka Dallas Nat. Ins. Co.

454-13-2420.M4

07-1594

Vista Hospital of Dallas

TASB Risk Management Fund

454-13-2438.M4

07-0120

Vista Hospital of Dallas

Midwest Employers Casualty Co.

454-13-2464.M4

06-0444

Vista Hospital of Dallas

TPCIGA for Lumbermens Mutual Casualty Co.

454-13-2517.M4

06-6002

Vista Hospital of Dallas

National American Insurance Co.

454-13-2520.M4

06-2351

Vista Hospital of Dallas

Transportation Insurance Co.

454-13-2540.M4

06-0627

Vista Medical Center Hospital

TPCIGA for Freestone Insurance fka Dallas Nat. Ins. Co.

454-13-2542.M4

03-3911

Vista Medical Center Hospital

ACIG Insurance Co.

454-13-2772.M4

07-3326

Vista Medical Center Hospital

Aberdeen Insurance Co.

454-13-3631.M4

09-3472

Vista Hospital of Dallas

Fidelity & Guaranty Ins. Co.

454-13-4367.M4

05-8699

Vista Hospital of Dallas

TPCIGA for Lumbermens Mutual Casualty Co.

454-13-4385.M4

07-5187

Vista Medical Center Hospital

Highlands Casualty Co.

454-13-4387.M4

07-1613

Vista Hospital of Dallas

TPCIGA for Am. Motorists Ins. Co.

454-13-4441.M4

07-4940

Vista Medical Center Hospital

Truck Insurance Exchange

454-13-4443.M4

07-5436

Vista Hospital of Dallas

TASB Risk Management Fund

454-13-4451.M4

07-8172

Vista Hospital of Dallas

TASB Risk Management Fund

454-13-4454.M4

08-0625

Vista Hospital of Dallas

United State Fire Ins. Co.

454-13-5037.M4

06-3888

Vista Medical Center Hospital

TPCIGA for Reliance National Ins.

454-13-5041.M4

08-6162

Vista Hospital of Dallas

TPCIGA for Centennial Ins. Co.

ATTACHMENT A Vista Consolidated Stop-Loss Cases

Part 3 of 3

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-5043.M4

06-3894

Vista Hospital of Dallas

Continental Cas. Co.

454-13-5052.M4

08-0113

Vista Hospital of Dallas

National Fire Insurance

454-13-5054.M4

03-7992

Vista Medical Center Hospital

TPCIGA for Am. Motorists Ins. Co.

454-13-5125.M4

05-2442

Vista Hospital of Dallas

Am. Cas. Co. of Reading, PA

454-13-5128.M4

05-A440

Vista Medical Center Hospital

TPCIGA for American Manufacturers Mutual Ins.

454-14-1844.M4

03-2847

Vista Medical Center Hospital

Zenith Insurance Co.

454-14-1846.M4

05-1993

Vista Medical Center Hospital

Transcontinental Insurance Co.

454-14-1851.M4

03-2265

Vista Medical Center Hospital

TPCIGA for Reliance National

454-14-1852.M4

03-2123

Vista Medical Center Hospital

Hartford Casualty Ins. Co.

454-14-1853.M4

03-6199

Vista Medical Center Hospital

TPCIGA for Credit General Indemnity

454-14-1854.M4

03-2230

Vista Medical Center Hospital

Hartford Casualty Ins. Co.

454-14-1855.M4

04-1001

Vista Medical Center Hospital

Texas Builders Insurance Co.

454-14-2077.M4

04-6031

Vista Medical Center Hospital

TPCIGA for Fremont Indemnity Co.

454-14-2078.M4

04-1024

Vista Medical Center Hospital

TPCIGA for Petrosurance Cas. Co.

454-14-2079.M4

04-6150

Vista Medical Center Hospital

TPCIGA for Fremont Indemnity Co.

454-14-2080.M4

04-4929

Vista Medical Center Hospital

TPCIGA for Paula Ins. Co.

454-14-2086.M4

07-1599

Vista Medical Center Hospital

Mid-Century Ins. Co.

454-14-2144.M4

04-6150

TPCIGA for Fremont Indemnity Co.

Vista Medical Center Hospital

454-14-2283.M4

03-2477

Vista Medical Center Hospital

Mid-Century Ins. Co.

454-15-1318.M4

08-6246

Surgery Specialty Hospitals of America

TASB Risk Management Fund

454-15-2438.M4

03-6225

Vista Medical Center Hospital

Transcontinental Insurance Co.

ATTACHMENT A Vista Consolidated Stop-Loss Cases

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-15-2434.M5

05-2400

Vista Medical Center Hospital

Ace Insurance Co. of Texas

454-15-2436.M5

05-2400

Ace Insurance Co. of Texas

Vista Medical Center Hospital

ATTACHMENT A Vista Consolidated Stop-Loss Cases

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-0416.M4

06-7050

Vista Medical Center Hospital

Jacobs Engineering Group Inc.

454-13-0530.M4

07-7030

Vista Medical Center Hospital

Ace American Insurance Co.

454-13-1361.M4

06-7656

Vista Hospital of Dallas

Lockheed Martin Corp.

454-13-1490.M4

07-7011

Vista Hospital of Dallas

Insurance Co. of the State of PA

454-13-1536.M4

07-0602

Vista Hospital of Dallas

International Paper Co.

454-13-1537.M4

07-3231

Vista Hospital of Dallas

Ace American Insurance Co.

454-13-2136.M4

08-1408

Vista Medical Center Hospital

Ace American Insurance Co.

454-13-2172.M4

07-2129

Vista Medical Center Hospital

Lowes Home Center Inc.

454-13-2173.M4

07-1020

Vista Medical Center Hospital

Ace American Insurance Co.

454-13-2177.M4

07-2600

Vista Medical Center Hospital

Pacific Employers Insurance Co.

454-13-2180.M4

04-6460

Vista Medical Center Hospital

Pacific Employers Insurance Co.

454-13-2414.M4

06-6271

Vista Medical Center Hospital

Jacobs Engineering Group Inc.

454-13-2446.M4

07-8177

Vista Hospital of Dallas

American Zurich Insurance Co.

454-13-2461.M4

06-1406

Vista Medical Center Hospital

Illinois National Insurance Co.

454-13-2466.M4

07-4012

Vista Hospital of Dallas

Federal Insurance Co.

454-13-3311.M4

07-7666

Vista Medical Center Hospital

K Mart Corporation

454-13-3324.M4

08-2806

Vista Hospital of Dallas

Ace American Insurance Co.

454-13-4584.M4

07-0668

Vista Medical Center Hospital

Ace American Insurance Co.

454-13-5039.M4

05-A692

Vista Hospital of Dallas

Great Northern Insurance Co.

454-13-5045.M4

06-6333

Vista Medical Center Hospital

Insurance Co. of North America

454-13-5177.M4

08-1498

Vista Hospital of Dallas

Ace American Insurance Co.

454-15-1313.M4

04-5632

Vista Medical Center Hospital

Onebeacon Insurance Co.

454-15-1334.M4

06-5881

Vista Medical Center Hospital

Pacific Employers Insurance Co.

454-15-2439.M4

04-3905

Vista Medical Center Hospital

TPCIGA for Reliance National

ATTACHMENT A Vista Consolidated Stop-Loss Cases

Part 1 of 3

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-0418.M4

06-2214

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-13-0423.M4

03-A371

Vista Medical Center Hospital

Liberty Insurance Corporation

454-13-0523.M4

06-5230

Vista Hospital of Dallas

Liberty Insurance Corporation

454-13-0603.M4

05-5455

Vista Hospital of Dallas

Liberty Mutual Fire Ins. Co.

454-13-0895.M4

08-6919

Vista Hospital of Dallas

Liberty Insurance Corporation

454-13-1461.M4

05-8119

Vista Medical Center Hospital

Liberty Insurance Corporation

454-13-1542.M4

07-0575

Vista Hospital of Dallas

Liberty Insurance Corporation

454-13-1549.M4

06-3108

Vista Hospital of Dallas

Wausau Underwriters Ins. Co.

454-13-2132.M4

07-0614

Vista Hospital of Dallas

Liberty Mutual Fire Ins. Co.

454-13-2139.M4

08-1644

Vista Hospital of Dallas

Liberty Mutual Fire Ins. Co.

454-13-2179.M4

06-6129

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-13-2182.M4

07-2672

Vista Hospital of Dallas

American States Ins. Co. of Texas

454-13-2186.M4

03-7974

Vista Medical Center Hospital

Employers Insurance Co. of Wausau

454-13-2189.M4

07-2647

Vista Hospital of Dallas

Employers Insurance Co. of Wausau

454-13-2192.M4

05-A559

Vista Hospital of Dallas

Liberty Insurance Corporation

454-13-2416.M4

08-1288

Vista Hospital of Dallas

Liberty Insurance Corporation

454-13-2417.M4

03-8976

Vista Medical Center Hospital

Liberty Insurance Corporation

454-13-2428.M4

09-6371

Surgery Specialty Hospital of America SE Houston Campus

Liberty Insurance Corporation

454-13-2435.M4

08-1645

Vista Hospital of Dallas

Liberty Insurance Corporation

454-13-2441.M4

06-5150

Vista Medical Center Hospital

Service Lloyds Insurance Co.

454-13-2468.M4

04-5545

Vista Medical Center Hospital

Texas Association of Counties RMP

454-13-2473.M4

04-0081

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-13-2475.M4

08-1415

Vista Hospital of Dallas

LM Insurance Corporation

454-13-2577.M4

06-6003

Vista Medical Center Hospital

Texas Association of Counties RMP

454-13-2871.M4

04-4847

Vista Medical Center Hospital

Wausau Business Insurance Co.

454-13-3320.M4

06-7710

Vista Hospital of Dallas

Liberty Insurance Corporation

454-13-3328.M4

06-7494

Vista Hospital of Dallas

Liberty Mutual Fire Ins. Co.

454-13-3331.M4

07-3126

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-13-3680.M4

06-6032

Vista Medical Center Hospital

Liberty Mutual Ins. Co.

454-13-3686.M4

07-6977

Vista Medical Center Hospital

Liberty Insurance Corporation

454-13-3690.M4

06-6820

Vista Medical Center Hospital

Liberty Mutual Ins. Co.

454-13-4263.M4

07-7414

Vista Hospital of Dallas

Liberty Insurance Corporation

454-13-4265.M4

08-1297

Vista Hospital of Dallas

LM Insurance Corporation

454-13-4275.M4

07-7007

Vista Hospital of Dallas

Liberty Insurance Corporation

454-13-4368.M4

05-A469

Vista Hospital of Dallas

Liberty Insurance Corporation

ATTACHMENT A Vista Consolidated Stop-Loss Cases

Part 2 of 3

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-4374.M4

05-A515

Vista Hospital of Dallas

Liberty Insurance Corporation

454-13-4375.M4

05-B128

Vista Hospital of Dallas

Liberty Mutual Ins. Co.

454-13-4462.M4

08-6245

Surgery Specialty Hospital of America

Liberty Mutual Fire Ins. Co.

454-13-5040.M4

06-5251

Vista Hospital of Dallas

Liberty Mutual Fire Ins. Co.

454-13-5126.M4

07-7344

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-13-5134.M4

09-7537

Vista Hospital of Dallas

Liberty Mutual Fire Ins. Co.

454-13-5164.M4

07-8178

Vista Hospital of Dallas

LM Insurance Corporation

454-13-5180.M4

08-3896

Vista Hospital of Dallas

Liberty Insurance Corporation

454-14-2285.M4

06-1982

Vista Medical Center Hospital

Liberty Mutual Ins. Co.

454-15-0048.M4

05-B552

Vista Hospital of Dallas

Liberty Mutual Fire Ins. Co.

454-15-0049.M4

04-0014

Vista Medical Center Hospital

Employers Insurance Co. of Wausau

454-15-0050.M4

05-B571

Vista Hospital of Dallas

Liberty Mutual Fire Ins. Co.

454-15-0051.M4

04-0486

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-15-0053.M4

03-2238

Vista Medical Center Hospital

Liberty Mutual Ins. Co.

454-15-0056.M4

03-6050

Vista Medical Center Hospital

Liberty Insurance Corporation

454-15-0057.M4

05-1115

Vista Hospital of Dallas

Liberty Mutual Fire Ins. Co.

454-15-0058.M4

03-1595

Vista Medical Center Hospital

Liberty Insurance Corporation

454-15-0059.M4

03-2194

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-15-0060.M4

03-2149

Vista Medical Center Hospital

Wausau Underwriters Ins. Co.

454-15-0061.M4

03-2229

Vista Medical Center Hospital

LM Insurance Corporation

454-15-0302.M4

03-1819

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-15-0303.M4

03-5571

Vista Medical Center Hospital

Mid-Century Ins. Co.

454-15-0304.M4

03-3045

Vista Medical Center Hospital

Employers Ins. Co. of Wausau

454-15-0305.M4

03-5855

Vista Medical Center Hospital

Liberty Insurance Corporation

454-15-0306.M4

03-5536

Vista Medical Center Hospital

Employers Ins. Co. of Wausau

454-15-0376.M4

04-7875

Vista Medical Center Hospital

Liberty Insurance Corporation

454-15-0378.M4

04-7893

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-15-0379.M4

04-8101

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-15-0381.M4

04-7825

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-15-0383.M4

04-7847

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-15-0384.M4

04-2251

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-15-0385.M4

04-5555

Vista Medical Center Hospital

Employers Ins. Co. of Wausau

454-15-0386.M4

04-3435

Vista Medical Center Hospital

Employers Ins. Co. of Wausau

454-15-0387.M4

04-6058

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-15-0388.M4

04-3571

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

ATTACHMENT A Vista Consolidated Stop-Loss Cases

Part 3 of 3

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-15-0389.M4

03-7251

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-15-0390.M4

04-0084

Vista Medical Center Hospital

Liberty Mutual Ins. Co.

454-15-0391.M4

03-9076

Vista Medical Center Hospital

Liberty Mutual Ins. Co.

454-15-0392.M4

04-1206

Vista Medical Center Hospital

LM Insurance Co.

454-15-0393.M4

03-9462

Vista Medical Center Hospital

Liberty Insurance Corporation

454-15-0559.M4

05-8455

Vista Hospital of Dallas

Liberty Mutual Fire Ins. Co.

454-15-0560.M4

05-B628

Vista Hospital of Dallas

Liberty Mutual Fire Ins. Co.

454-15-0562.M4

06-2263

Vista Hospital of Dallas

Liberty Mutual Fire Ins. Co.

454-15-0563.M4

05-2671

Vista Hospital of Dallas

Liberty Insurance Corporation

454-15-0564.M4

05-5333

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-15-0565.M4

05-2675

Vista Hospital of Dallas

Employers Ins. Co. of Wausau

454-15-0566.M4

05-6932

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-15-0568.M4

05-1648

Vista Medical Center Hospital

Liberty Mutual Ins. Co.

454-15-0569.M4

05-2051

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-15-0571.M4

05-2669

Vista Hospital of Dallas

Liberty Mutual Fire Ins. Co.

454-15-0572.M4

05-2050

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-15-0598.M4

04-7891

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-15-0602.M4

04-5369

Vista Medical Center Hospital

Liberty Insurance Corporation

454-15-0708.M4

04-0263

Vista Medical Center Hospital

Employers Ins. Co. of Wausau

454-15-0710.M4

06-2643

Vista Hospital of Dallas

Liberty Insurance Corporation

454-15-0712.M4

05-3533

Vista Hospital of Dallas

Liberty Insurance Corporation

454-15-0713.M4

04-A011

Vista Medical Center Hospital

Liberty Insurance Corporation

454-15-0715.M4

04-5685

Vista Medical Center Hospital

Liberty Insurance Corporation

454-15-0716.M4

04-6407

Vista Medical Center Hospital

JC Penny Corporation Inc.

454-15-0717.M4

04-5990

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

454-15-0718.M4

04-6331

Vista Medical Center Hospital

LM Insurance Corporation

454-16-0691.M4

03-9105

Vista Medical Center Hospital

Liberty Mutual Fire Ins. Co.

ATTACHMENT A Vista Consolidated Stop-Loss Cases

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-4254.M4

08-0133

Vista Hospital of Dallas

University of Texas System

ATTACHMENT A Vista Consolidated Stop-Loss Cases

Page 1 of 5

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-12-1961.M4

06-6001

Vista Medical Center Hospital

Zurich American Insurance Co.

454-12-2515.M4

06-5999

Vista Medical Center Hospital

Insurance Co. of the State of PA

454-12-4717.M4

06-6813

Vista Medical Center Hospital

American Home Assurance Co.

454-12-5113.M4

04-4886

Vista Medical Center Hospital

Insurance Co. of the State of PA

454-12-5429.M4

05-2357

Vista Hospital of Dallas

Sentry Insurance Co.

454-12-5431.M4

05-6406

Vista Hospital of Dallas

Zurich American Insurance Co.

454-12-5500.M4

05-6722

Vista Hospital of Dallas

Insurance Co. of the State of PA

454-12-5562.M4

06-0427

Vista Hospital of Dallas

Dallas ISD

454-12-5563.M4

05-B068

Vista Hospital of Dallas

Amer. Guarantee & Liability Ins.

454-12-5565.M4

06-2096

Vista Hospital of Dallas

Albertsons Inc.

454-12-5566.M4

05-9499

Vista Hospital of Dallas

RCH Protect Cooperative

454-12-5568.M4

05-1381

Vista Medical Center Hospital

American Home Assurance Co.

454-12-5569.M4

06-6231

Vista Medical Center Hospital

Commerce & Industry Ins. Co.

454-12-5858.M4

05-2250

Vista Medical Center Hospital

Zurich American Insurance Co.

454-12-5859.M4

04-6132

Vista Medical Center Hospital

Illinois National Ins. Co.

454-12-5860.M4

05-A450

Vista Medical Center Hospital

American Zurich Insurance Co.

454-12-5861.M4

06-2054

Vista Hospital of Dallas

Zurich American Insurance Co.

454-12-5864.M4

06-6082

Vista Medical Center Hospital

Fidelity & Guaranty Ins. Co.

454-12-5957.M4

06-6819

Vista Medical Center Hospital

Commerce & Industry Ins. Co.

454-12-5958.M4

06-7047

Vista Medical Center Hospital

Commerce & Industry Ins. Co.

454-12-6021.M4

08-0068

Vista Hospital of Dallas

Zurich American Insurance Co.

454-12-6121.M4

05-8105

Vista Medical Center Hospital

Facility Insurance Corp.

454-12-6572.M4

06-6235

Vista Medical Center Hospital

TML Intergovernmental Risk Pool

454-12-7032.M4

06-6080

Vista Medical Center Hospital

Facility Insurance Corp.

454-12-7146.M4

03-7989

Vista Medical Center Hospital

American Zurich Insurance Co.

454-12-7149.M4

06-7060

Vista Medical Center Hospital

Fidelity & Guaranty Ins. Co.

454-12-7150.M4

06-6795

Vista Medical Center Hospital

Commerce & Industry Ins. Co.

454-12-7312.M4

07-0731

Vista Medical Center Hospital

Zurich American Insurance Co.

454-12-7313.M4

07-2867

Vista Medical Center Hospital

Zurich American Insurance Co.

454-12-7314.M4

09-3488

Vista Hospital of Dallas

Zurich American Insurance Co.

454-12-7316.M4

07-0172

Vista Hospital of Dallas

Zurich American Insurance Co.

454-12-7320.M4

06-6826

Vista Medical Center Hospital

Zurich American Insurance Co.

454-12-7333.M4

07-4046

American Home Assurance Co.

Vista Medical Center Hospital

454-12-7495.M4

04-6315

Vista Medical Center Hospital

American Insurance Co.

454-12-7838.M4

06-1611

Facility Insurance Corp.

Vista Medical Center Hospital

454-13-0105.M4

07-4673

American Guarantee & Liability Ins.

Vista Hospital of Dallas

454-13-0106.M4

07-1021

Employers Mutual Casualty Co.

Vista Hospital of Dallas

ATTACHMENT A Vista Consolidated Stop-Loss Cases

Page 2 of 5

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-0107.M4

08-5035

American Guarantee & Liability Ins.

Vista Hospital of Dallas

454-13-0108.M4

07-4151

Zurich American Insurance Co.

Vista Medical Center Hospital

454-13-0140.M4

06-0659

Gray Insurance Co.

Vista Medical Center Hospital

454-13-0517.M4

09-6009

Surgery Specialty Hospital of Amer.

Amer. Guarantee & Liability Ins.

454-13-0518.M4

09-4686

Vista Hospital of Dallas

Insurance Co. of the State of PA

454-13-0519.M4

09-2399

Surgery Specialty Hospital of Amer.

Zurich American Insurance Co.

454-13-0520.M4

07-0060

Vista Hospital of Dallas

Zurich American Insurance Co.

454-13-0521.M4

07-0600

Vista Hospital of Dallas

Dallas ISD

454-13-0524.M4

06-6000

Vista Hospital of Dallas

East TX Educational Ins. Assoc.

454-13-0525.M4

06-6004

Vista Medical Center Hospital

Commerce & Industry Ins. Co.

454-13-0526.M4

07-0601

Vista Hospital of Dallas

Amer. Guarantee & Liability Ins.

454-13-0527.M4

07-1868

Vista Hospital of Dallas

Amer. Guarantee & Liability Ins.

454-13-0529.M4

07-4151

Vista Medical Center Hospital

Zurich American Insurance Co.

454-13-0531.M4

07-7038

Vista Hospital of Dallas

Insurance Co. of the State of PA

454-13-0532.M4

08-0199

Vista Hospital of Dallas

Zurich American Insurance Co.

454-13-0896.M4

08-4985

Vista Medical Center Hospital

Commerce & Industry Ins. Co.

454-13-1278.M4

09-6011

Surgery Specialty Hospital of American SE Houston Campus

Ace American Insurance Co.

454-13-1406.M4

07-3984

Vista Medical Center Hospital

American Home Assurance Co.

454-13-1407.M4

07-8133

Vista Medical Center Hospital

Zurich American Insurance Co.

454-13-1408.M4

07-4026

Vista Hospital of Dallas

Zurich American Insurance Co.

454-13-1409.M4

07-0726

Vista Hospital of Dallas

Harbor Specialty Insurance Co.

454-13-1410.M4

07-3130

Vista Medical Center Hospital

Insurance Co. of the State of PA

454-13-1411.M4

08-1472

Vista Hospital of Dallas

Commerce & Industry Ins. Co.

454-13-1412.M4

07-3222

Vista Medical Center Hospital

Fidelity & Guaranty Insurance Co.

454-13-1463.M4

07-4000

Vista Hospital of Dallas

New Hampshire Insurance Co.

454-13-1464.M4

08-1294

Vista Hospital of Dallas

New Hampshire Insurance Co.

454-13-1465.M4

07-3993

Vista Medical Center Hospital

Insurance Co. of the State of PA

454-13-1466.M4

08-2803

Vista Medical Center Hospital

American Home Assurance Co.

454-13-1467.M4

07-4010

Vista Hospital of Dallas

Zurich American Insurance Co.

454-13-1468.M4

08-2804

Vista Hospital of Dallas

Sentry Insurance Co.

454-13-1469.M4

07-3972

Vista Medical Center Hospital

Insurance Co. of the State of PA

454-13-1470.M4

08-5039

Vista Medical Center Hospital

Insurance Co. of the State of PA

454-13-1471.M4

08-1305

Vista Hospital of Dallas

American Home Assurance Co.

454-13-1472.M4

07-2077

Vista Medical Center Hospital

Insurance Co. of the State of PA

454-13-1486.M4

06-2925

Vista Hospital of Dallas

American Home Assurance Co.

454-13-1491.M4

09-6427

Vista Hospital of Dallas

Zurich American Insurance Co.

ATTACHMENT A Vista Consolidated Stop-Loss Cases

Page 3 of 5

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-1492.M4

07-7022

Vista Medical Center Hospital

Sentry Insurance Co.

454-13-1493.M4

07-7857

Vista Medical Center Hospital

Bituminous Cas. Corporation

454-13-1535.M4

07-7768

Vista Hospital of Dallas

Federated Mutual Insurance Co.

454-13-1540.M4

09-6031

Vista Hospital of Dallas

American Home Assurance Co.

454-13-1541.M4

08-1441

Vista Hospital of Dallas

New Hampshire Insurance Co.

454-13-1545.M4

08-2355

Vista Hospital of Dallas

Insurance Co. of the State of PA

454-13-2121.M4

03-9084

Vista Medical Center Hospital

Continental Cas. Co.

454-13-2125.M4

07-2680

Vista Hospital of Dallas

Zurich American Insurance Co.

454-13-2129.M4

07-1008

Vista Hospital of Dallas

Hartford Underwriters Ins. Co.

454-13-2130.M4

07-4044

Vista Hospital of Dallas

East TX Educational Ins. Assoc.

454-13-2131.M4

08-6248

Vista Hospital of Dallas

American Home Assurance Co.

454-13-2141.M4

07-4673

Vista Hospital of Dallas

American Guarantee & Liability Ins.

454-13-2176.M4

08-6247

Surgery Specialty Hospital of America SE Houston Campus

Zurich American Insurance Co.

454-13-2190.M4

03-8005

Vista Medical Center Hospital

Lumbermens Mutual Casualty Co.

454-13-2432.M4

08-6161

Vista Hospital of Dallas

East TX Educational Ins. Assoc.

454-13-2437.M4

08-2899

Vista Hospital of Dallas

Zurich American Insurance Co.

454-13-2452.M4

07-2180

Vista Medical Center Hospital

Zurich American Insurance Co.

454-13-2453.M4

08-1749

Vista Hospital of Dallas

American Home Assurance Co.

454-13-2455.M4

07-0728

Vista Hospital of Dallas

American Home Assurance Co.

454-13-2462.M4

08-1293

Vista Medical Center Hospital

America First Lloyds Insurance

454-13-2463.M4

05-B592

Vista Hospital of Dallas

TML Intergovernmental Risk Pool

454-13-2476.M4

06-6236

Vista Medical Center Hospital

Commerce & Industry Ins. Co.

454-13-2477.M4

06-5234

Vista Hospital of Dallas

American Insurance Co.

454-13-2514.M4

07-3199

Vista Hospital of Dallas

Royal Ins. Co. of America

454-13-2541.M4

05-B563

Vista Hospital of Dallas

Zurich American Insurance Co.

454-13-2723.M4

07-4046

Vista Medical Center Hospital

American Home Assurance Co.

454-13-2866.M4

07-1012

Vista Medical Center Hospital

Commerce & Industry Ins. Co.

454-13-2867.M4

07-0952

Vista Medical Center Hospital

Amer. Guarantee & Liability Ins.

454-13-2868.M4

07-0091

Vista Medical Center Hospital

Amer. Guarantee & Liability Ins.

454-13-2870.M4

06-2156

Vista Hospital of Dallas

WC Solutions

454-13-2872.M4

06-1611

Vista Medical Center Hospital

Facility Insurance Corp.

454-13-3168.M4

07-0110

Vista Hospital of Dallas

Nationwide Mutual Fire Ins. Co.

454-13-3187.M4

07-0110

Nationwide Mutual Fire Ins. Co.

Vista Hospital of Dallas

454-13-3317.M4

07-4294

Vista Hospital of Dallas

TPCIGA for Reliance National

454-13-3325.M4

07-2857

Vista Hospital of Dallas

Liberty Mutual Fire Ins. Co.

ATTACHMENT A Vista Consolidated Stop-Loss Cases

Page 4 of 5

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-3410.M4

08-5573

Surgery Specialty Hospital of America SE Houston Campus

Old Glory Insurance Co.

454-13-3687.M4

07-1591

Vista Medical Center Hospital

Royal Ins. Co. of America

454-13-3688.M4

08-4938

Vista Medical Center Hospital

Houston General Insurance Co.

454-13-3987.M4

08-4929

Vista Hospital of Dallas

Facility Insurance Corp.

454-13-4271.M4

05-7994

Vista Medical Center Hospital

Beaumont ISD

454-13-4377.M4

06-2094

Vista Hospital of Dallas

Security Insurance Co. of Hartford

454-13-4383.M4

04-7873

Vista Medical Center Hospital

Target Corporation

454-13-4437.M4

07-2705

Vista Medical Center Hospital

American Zurich Insurance Co.

454-13-4439.M4

07-4011

Vista Medical Center Hospital

Houston General Insurance Co.

454-13-4446.M4

07-7388

Vista Medical Center Hospital

Houston General Insurance Co.

454-13-4450.M4

07-8009

Vista Hospital of Dallas

Federated Mutual Ins. Co.

454-13-4455.M4

08-1389

Vista Hospital of Dallas

Old Republic Insurance Co.

454-13-4456.M4

08-1659

Vista Hospital of Dallas

Hartford Underwriters Ins. Co.

454-13-4458.M4

08-4982

Surgery Specialty Hospital of America

Federated Mutual Ins. Co.

454-13-4460.M4

08-5430

Surgery Specialty Hospital of America

TML Intergovernmental Risk Pool

454-13-4464.M4

09-5953

Vista Hospital of Dallas

American Home Assurance Co.

454-13-4466.M4

09-6308

Surgery Specialty Hospital of America

Commerce & Industry Ins. Co.

454-13-4577.M4

03-2855

Vista Medical Center Hospital

Ace Insurance Co. of Texas

454-13-4585.M4

08-6250

Surgery Specialty Hospital of America

Amer. Guarantee & Liability Ins.

454-13-5036.M4

06-5138

Vista Hospital of Dallas

St. Paul Fire & Marine Ins. Co.

454-13-5130.M4

09-4878

Surgery Specialty Hospital of America

Indemnity Insurance Co. of North

454-13-5168.M4

05-8432

Vista Hospital of Dallas

Zurich American Insurance Co.

454-13-5171.M4

04-3345

Vista Medical Center Hospital

Insurance Co. of the State of PA

454-13-6110.M4

06-5310

Vista Hospital of Dallas

American Home Assurance Co.

454-14-0080.M4

07-7741

VHD 0 SSIC

Sentry Insurance Co.

454-14-0081.M4

03-5858

Vista Medical Center Hospital

Zurich American Insurance Co.

454-14-0468.M4

07-8170

Vista Medical Center Hospital

American Zurich Insurance Co.

454-14-2363.M4

09-4874

Surgery Specialty Hospital of America

Zurich American Insurance Co.

454-14-2394.M4

07-6990

Vista Hospital of Dallas

WC Solutions

454-14-2858.M4

09-6270

Vista Hospital of Dallas

American Home Assurance Co.

454-15-1312.M4

07-4048

Vista Hospital of Dallas

Albertson Inc.

ATTACHMENT A Vista Consolidated Stop-Loss Cases

Page 5 of 5

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-15-1316.M4

07-4629

Vista Medical Center Hospital

Commerce & Industry Ins. Co.

454-15-1317.M4

07-8215

Vista Medical Center Hospital

Zurich American Insurance Co.

454-15-1319.M4

08-0064

Vista Hospital of Dallas

Fidelity & Guaranty Insurance Co.

454-15-1320.M4

08-0067

Vista Hospital of Dallas

Insurance Co. of the State of PA

454-15-1330.M4

07-3992

Vista Medical Center Hospital

American Home Assurance Co.

454-15-1331.M4

07-2666

Vista Hospital of Dallas

American Guarantee & Liability Ins.

454-15-1333.M4

07-0122

Vista Hospital of Dallas

Dallas ISD

ATTACHMENT A Vista Consolidated Stop-Loss Cases

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-3314.M4

08-2856

Vista Hospital of Dallas

Dallas County

ATTACHMENT A Vista Consolidated Stop-Loss Cases

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-0522.M4

06-5151

Vista Medical Center Hospital

Bankers Standard Insurance Co.

454-13-1543.M4

06-2213

Vista Hospital of Dallas

Bankers Standard Insurance Co.

ATTACHMENT A Vista Consolidated Stop-Loss Cases

SOAH DKT NO.

MR NO.

PETITIONER

RESPONDENT

454-13-1487.M4

05-4623

Vista Hospital of Dallas

Insurance Co. of the State of PA

454-13-2184.M4

07-8134

Vista Hospital of Dallas

St. Paul Fire & Marine Ins. Co.

454-13-2423.M4

07-2127

Vista Hospital of Dallas

Travelers Indemnity Co. of Connecticut

454-13-2424.M4

06-0415

Vista Hospital of Dallas

Travelers Indemnity Co. of Connecticut

454-13-2425.M4

04-5059

Vista Medical Center Hospital

MetLife Insurance Co. of Conn.

454-13-3679.M4

08-4935

Vista Hospital of Dallas

Travelers Indemnity Co. of Connecticut

454-13-4274.M4

07-4685

Vista Hospital of Dallas

Travelers Indemnity Co.

454-13-4364.M4

04-8156

Vista Medical Center Hospital

Travelers Indemnity Co. of Connecticut

454-13-4376.M4

05-B242

Vista Medical Center Hospital

Travelers Casualty & Surety Co.

454-13-4382.M4

04-1365

Vista Medical Center Hospital

Travelers Indemnity Co. of Connecticut

454-13-4445.M4

07-7047

Vista Hospital of Dallas

St. Paul Fire & Marine Ins. Co.

454-13-4447.M4

07-7417

Vista Hospital of Dallas

St. Paul Fire & Marine Ins. Co.

454-13-4448.M4

07-7667

Vista Hospital of Dallas

Travelers Indemnity Co. of Connecticut

454-13-4449.M4

07-7742

Vista Hospital of Dallas

St. Paul Fire & Marine Ins. Co.

454-13-5056.M4

03-3672

Vista Medical Center Hospital

Travelers Indemnity Co. of America

454-13-2860.M4

07-4122

Vista Hospital of Dallas

Travelers Property Casualty Co.

454-13-1314.M4

03-A346

Vista Medical Center Hospital

Phoenix Insurance Co.

ATTACHMENT 1

Page 1 of 1

CASE REIMBURSED UNDER STOP-LOSS EXCEPTION

NO.

SOAH Dkt. No.

MR No.

Post Audit

Billed Charges

Total Owed

Carrier Payment

Additional Reimbursement Owed to Provider

1

454-13-3309.M4

06-7626

$273,647.84

$205,235.88

$138,430.13

$66,805.75

2

454-12-7728.M4

03-7954

$173,888.29

$130,416.22

$74,551.05

$55,865.17

3

454-12-7958.M4

03-3974

$164,005.28

$123,003.96

$106,574.45

$16,429.51

4

454-13-5128.M4

05-A440

$392,539.86

$294,404.90

$88,519.32

$205,885.58

5

454-13-2180.M4

04-6460

$119,518.49

$89,638.87

$14,873.80

$74,765.07

6

454-13-0423.M4

03-A371

$197,188.79

$147,891.59

$109,435.04

$38,456.55

7

454-13-1549.M4

06-3108

$181,049.42

$135,787.07

$84,595.51

$51,191.56

8

454-13-2870.M4

06-2156

$129,654.00

$97,240.50

$12,298.00

$84,942.50

9

454-13-3168.M4

07-0110

$223,866.45

$167,899.84

$59,371.82

$108,528.02

10

454-13-3187.M4

07-0110

See 454-13-3168.M4

See 454-13-3168.M4

See 454-13-3168.M4

See 454-13-3168.M4

11

454-13-4320.M4

06-4328

$131,353.50

$98,515.13

$89,247.77

$9,267.36

12

454-13-1788.M4

06-2835

$69,368.17

$52,026.13

$16,907.05

$35,119.08

13

454-13-1853.M4

08-7019

$208,313.00

$156,234.75

$36,192.00

$120,042.75

14

454-13-4196.M4

07-4526

$179,863.10

$134,747.33

$0.00

$134,897.33

ATTACHMENT 2

Page 1 of 13

NO ADDITIONAL REIMBURSEMENT OWED TO PROVIDER

NO.

SOAH Dkt. No.

MR No.

Carrier Payment

Additional Reimbursement Owed to Provider

1

454-13-0141.M4

06-2077

See 454-13-0419

$0.00

2

454-13-0143.M4

06-2270

See 454-13-0417

$0.00

3

454-13-0417.M4

06-2270

$21,901.52

$0.00

4

454-13-0419.M4

06-2077

$17,500.00

$0.00

5

454-13-0420.M4

03-9053

$24,580.88

$0.00

6

454-13-0898.M4

05-A922

$28,492.06

$0.00

7

454-13-0899.M4

05-8001

$12,902.50

$0.00

8

454-13-0989.M4

08-1759

$27,664.00

$0.00

9

454-13-1538.M4

07-8171

$21,128.50

$0.00

10

454-13-1547.M4

06-2300

$26,069.00

$0.00

11

454-13-1550.M4

07-2560

$18,923.00

$0.00

12

454-13-1605.M4

07-4568

$21,269.36

$0.00

13

454-13-2126.M4

07-0571

$19,645.00

$0.00

14

454-13-2127.M4

06-5194

$14,466.60

$0.00

15

454-13-2135.M4

07-7746

$28,291.00

$0.00

16

454-13-2188.M4

07-3964

$22,743.45

$0.00

17

454-13-2427.M4

07-7060

$22,810.46

$0.00

18

454-13-2430.M4

06-3550

$17,152.00

$0.00

19

454-13-2445.M4

07-4045

$13,321.25

$0.00

20

454-13-2450.M4

07-7352

$24,199.00

$0.00

21

454-13-2774.M4

08-6234

$7,718.00

$0.00

22

454-13-2776.M4

07-4976

$11,169.58

$0.00

23

454-13-3300.M4

08-4499

$19,594.00

$0.00

24

454-13-3306.M4

07-5511

$11,129.50

$0.00

25

454-13-3312.M4

07-5191

$20,220.30

$0.00

26

454-13-3327.M4

06-7727

$25,787.00

$0.00

27

454-13-3334.M4

06-6823

$6,563.00

$0.00

28

454-13-3691.M4

07-0727

$16,347.20

$0.00

29

454-13-3694.M4

05-4551

$28,773.20

$0.00

30

454-13-4259.M4

07-5293

$28,093.41

$0.00

31

454-13-4381.M4

04-1080

$29,862.88

$0.00

32

454-13-4386.M4

07-0576

$18,312.50

$0.00

33

454-13-4440.M4

07-4038

$23,321.75

$0.00

34

454-13-4459.M4

08-4997

$6,612.50

$0.00

35

454-13-4463.M4

09-3486

$16,276.00

$0.00

To assist counsel, a Bold entry denominates the start of cases for a particular Provider or Carrier attorney.

ATTACHMENT 2

Page 2 of 13

NO ADDITIONAL REIMBURSEMENT OWED TO PROVIDER

NO.

SOAH Dkt. No.

MR No.

Carrier Payment

Additional Reimbursement Owed to Provider

36

454-13-4583.M4

03-9085

$3,354.00

$0.00

37

454-13-5055.M4

06-2396

$39,431.80

$0.00

38

454-14-2857.M4

14-1734

$15,197.00

$0.00

39

454-15-1335.M4

06-2223

$50,344.66

$0.00

40

454-15-1336.M4

05-6409

$19,756.50

$0.00

41

454-14-2085.M4

06-3910

$52,763.10

$0.00

42

454-13-2140.M4

07-2209

$12,930.75

$0.00

43

454-13-3685.M4

09-5185

$36,977.88

$0.00

44

454-13-4278.M4

09-6344

$6,656.00

$0.00

45

454-13-2415.M4

06-6524

$26,836.90

$0.00

46

454-13-2187.M4

05-4763

$11,398.50

$0.00

47

454-12-7449.M4

06-2240

$25,842.66

$0.00

48

454-12-7450.M4

06-2391

$19,990.20

$0.00

49

454-12-7451.M4

06-2625

$28,328.00

$0.00

50

454-12-7501.M4

05-B626

$17,898.90

$0.00

51

454-12-7505.M4

04-7872

$37,983.43

$0.00

52

454-12-7514.M4

04-6524

$11,517.55

$0.00

53

454-12-7709.M4

04-4839

$15,851.00

$0.00

54

454-12-7711.M4

04-1629

$10,200.40

$0.00

55

454-12-7713.M4

04-B490

$33,575.65

$0.00

56

454-12-7716.M4

04-7849

$22,913.84

$0.00

57

454-12-7717.M4

03-A580

$24,445.65

$0.00

58

454-12-7729.M4

03-8985

$48,344.49

$0.00

59

454-12-7731.M4

04-4031

$38,209.56

$0.00

60

454-12-7732.M4

04-3841

$76,918.84

$0.00

61

454-12-7733.M4

05-6933

$47,264.42

$0.00

62

454-12-7734.M4

04-6514

$55,782.22

$0.00

63

454-12-7736.M4

04-6054

$70,542.14

$0.00

64

454-12-7738.M4

04-5607

$58,941.20

$0.00

65

454-12-7740.M4

04-6048

$32,878.00

$0.00

66

454-12-7742.M4

03-2228

$31,989.73

$0.00

67

454-12-7743.M4

03-1728

$33,997.02

$0.00

68

454-12-7745.M4

05-1477

$17,198.11

$0.00

69

454-12-7747.M4

04-3359

$57,067.72

$0.00

70

454-12-7957.M4

04-3770

$94,958.90

$0.00

ATTACHMENT 2

Page 3 of 13

NO ADDITIONAL REIMBURSEMENT OWED TO PROVIDER

NO.

SOAH Dkt. No.

MR No.

Carrier Payment

Additional Reimbursement Owed to Provider

71

454-12-7959.M4

04-5383

$20,447.50

$0.00

72

454-12-7960.M4

03-5820

$83,204.08

$0.00

73

454-12-7961.M4

04-2253

$24,812.00

$0.00

74

454-12-7962.M4

04-6388

$46,304.83

$0.00

75

454-12-7963.M4

04-3351

$41,817.41

$0.00

76

454-12-7964.M4

05-3457

$75,460.09

$0.00

77

454-12-7965.M4

03-8491

$37,689.50

$0.00

78

454-13-0983.M4

07-7015

$48,376.99

$0.00

79

454-13-1118.M4

05-5193

$17,780.20

$0.00

80

454-13-1120.M4

04-7834

$48,937.20

$0.00

81

454-13-1124.M4

06-7709

$1,118.00

$0.00

82

454-13-2138.M4

07-1482

$14,414.77

$0.00

83

454-13-2420.M4

07-1594

$43,623.62

$0.00

84

454-13-2438.M4

07-0120

$17,670.50

$0.00

85

454-13-2517.M4

06-6002

$39,548.14

$0.00

86

454-13-2520.M4

06-2351

$25,227.50

$0.00

87

454-13-2542.M4

03-3911

$10,843.50

$0.00

88

454-13-2772.M4

07-3326

$30,073.90

$0.00

89

454-13-3631.M4

09-3472

$36,742.21

$0.00

90

454-13-4385.M4

07-5187

$15,449.60

$0.00

91

454-13-4387.M4

07-1613

$20,219.50

$0.00

92

454-13-4451.M4

07-8172

$51,598.76

$0.00

93

454-13-4454.M4

08-0625

$68,833.31

$0.00

94

454-13-5037.M4

06-3888

$53,645.09

$0.00

95

454-13-5041.M4

08-6162

$2,236.00

$0.00

96

454-13-5043.M4

06-3894

$23,444.40

$0.00

97

454-13-5052.M4

08-0113

$28,133.00

$0.00

98

454-13-5054.M4

03-7992

$83,417.79

$0.00

99

454-14-1844.M5

03-2847

$24,668.40

$0.00

100

454-14-1846.M5

05-1993

$5,590.00

$0.00

101

454-14-1851.M4

03-2265

$11,500.50

$0.00

102

454-14-1852.M4

03-2123

$16,981.50

$0.00

103

454-14-1853.M4

03-6199

$34,981.32

$0.00

104

454-14-1854.M4

03-2230

$27,367.50

$0.00

105

454-14-2077.M4

04-6031

$37,768.46

$0.00

ATTACHMENT 2

Page 4 of 13

NO ADDITIONAL REIMBURSEMENT OWED TO PROVIDER

NO.

SOAH Dkt. No.

MR No.

Carrier Payment

Additional Reimbursement Owed to Provider

106

454-14-2078.M4

04-1024

$58,247.52

$0.00

107

454-14-2079.M4

04-6150

$77,553.33

$0.00

108

454-14-2080.M4

04-4929

$45,833.53

$0.00

109

454-14-2144.M4

04-6150

See 454-14-2079.M4

See 454-14-2079.M4

110

454-14-2283.M4

03-2477

$102,931.37

$0.00

111

454-15-1318.M4

08-6246

$51,713.06

$0.00

112

454-15-2438.M4

03-6225

$65,606.14

$0.00

113

454-15-2434.M5

05-2400

$62,700.15

$0.00

114

454-15-2436.M5

05-2400

See 454-14.2434.M5

$0.00

115

454-13-0530.M4

07-7030

$52,229.38

$0.00

116

454-13-1361.M4

06-7656

$7,177.90

$0.00

117

454-13-1490.M4

07-7011

$21,999.00

$0.00

118

454-13-1536.M4

07-0602

$12,230.60

$0.00

119

454-13-1537.M4

07-3231

$21,468.40

$0.00

120

454-13-2172.M4

07-2129

$81,022.70

$0.00

121

454-13-2173.M4

07-1020

$11,883.00

$0.00

122

454-13-2177.M4

07-2600

$13,302.40

$0.00

123

454-13-3311.M4

07-7666

$16,938.00

$0.00

124

454-13-3324.M4

08-2806

$66,495.65

$0.00

125

454-13-5039.M4

05-A692

$47,229.58

$0.00

126

454-13-5177.M4

08-1498

$12,915.20

$0.00

127

454-15-1313.M4

04-5632

$44,896.80

$0.00

128

454-15-1334.M4

06-5881

$43,952.35

$0.00

129

454-15-2439.M4

04-3905

$20,705.07

$0.00

130

454-13-0418.M4

06-2214

$81,785.13

$0.00

131

454-13-0523.M4

06-5230

$9,763.10

$0.00

132

454-13-0603.M4

05-5455

$41,165.35

$0.00

133

454-13-0895.M4

08-6919

$23,459.50

$0.00

134

454-13-1461.M4

05-8119

$84,303.30

$0.00

135

454-13-2132.M4

07-0614

$10,198.50

$0.00

136

454-13-2139.M4

08-1644

$12,191.00

$0.00

137

454-13-2179.M4

06-6129

$66,765.25

$0.00

138

454-13-2182.M4

07-2672

$16,522.10

$0.00

139

454-13-2189.M4

07-2647

$32,244.00

$0.00

140

454-13-2192.M4

05-A559

$49,448.05

$0.00

ATTACHMENT 2

Page 5 of 13

NO ADDITIONAL REIMBURSEMENT OWED TO PROVIDER

NO.

SOAH Dkt. No.

MR No.

Carrier Payment

Additional Reimbursement Owed to Provider

141

454-13-2416.M4

08-1288

$14,239.60

$0.00

142

454-13-2417.M4

03-8976

$37,461.53

$0.00

143

454-13-2441.M4

06-5150

$4,363.00

$0.00

144

454-13-2468.M4

04-5545

$60,689.55

$0.00

145

454-13-2473.M4

04-0081

$74,267.55

$0.00

146

454-13-2475.M4

08-1415

$16,983.00

$0.00

147

454-13-2577.M4

06-6003

$1,417.00

$0.00

148

454-13-2871.M4

04-4847

$67,295.48

$0.00

149

454-13-3320.M4

06-7710

$2,236.00

$0.00

150

454-13-3328.M4

06-7494

$18,382.20

$0.00

151

454-13-3331.M4

07-3126

$25,445.65

$0.00

152

454-13-3680.M4

06-6032

$4,784.00

$0.00

153

454-13-3690.M4

06-6820

$144,928.41

$0.00

154

454-13-4263.M4

07-7414

$18,967.40

$0.00

155

454-13-4275.M4

07-7007

$19,753.50

$0.00

156

454-13-4368.M4

05-A469

$37,390.17

$0.00

157

454-13-4374.M4

05-A515

$15,816.60

$0.00

158

454-13-4375.M4

05-B128

$4,583.00

$0.00

159

454-13-4462.M4

08-6245

$14,645.50

$0.00

160

454-13-5134.M4

09-7537

$242,088.49

$0.00

161

454-13-5164.M4

07-8178

$21,262.00

$0.00

162

454-13-5180.M4

08-3896

$10,045.32

$0.00

163

454-14-2285.M4

06-1982

$93,171.31

$0.00

164

454-15-0048.M4

05-B552

$11,564.00

$0.00

165

454-15-0049.M4

04-0014

$70,466.50

$0.00

166

454-15-0050.M4

05-B571

$47,787.03

$0.00

167

454-15-0051.M4

04-0486

$55,842.08

$0.00

168

454-15-0053.M4

03-2238

$69,112.49

$0.00

169

454-15-0056.M4

03-6050

$58,546.75

$0.00

170

454-15-0057.M4

05-1115

$35,448.21

$0.00

171

454-15-0059.M4

03-2194

$76,398.80

$0.00

172

454-15-0060.M4

03-2149

$82,754.17

$0.00

173

454-15-0061.M4

03-2229

$66,114.53

$0.00

174

454-15-0302.M4

03-1819

$63,111.51

$0.00

175

454-15-0303.M4

03-5571

$76,212.71

$0.00

176

454-15-0304.M4

03-3045

$51,536.24

$0.00

177

454-15-0305.M4

03-5855

$63,434.22

$0.00

ATTACHMENT 2

Page 6 of 13

NO ADDITIONAL REIMBURSEMENT OWED TO PROVIDER

NO.

SOAH Dkt. No.

MR No.

Carrier Payment

Additional Reimbursement Owed to Provider

178

454-15-0306.M4

03-5536

$60,119.03

$0.00

179

454-15-0376.M4

04-7875

$67,974.90

$0.00

180

454-15-0378.M4

04-7893

$56,420.00

$0.00

181

454-15-0379.M4

04-8101

$67,545.64

$0.00

182

454-15-0381.M4

04-7825

$48,803.14

$0.00

183

454-15-0383.M4

04-7847

$82,787.20

$0.00

184

454-15-0384.M4

04-2251

$82,317.82

$0.00

185

454-15-0385.M4

04-5555

$60,830.59

$0.00

186

454-15-0386.M4

04-3435

$45,903.69

$0.00

187

454-15-0388.M4

04-3571

$68,506.45

$0.00

188

454-15-0389.M4

03-7251

$38,239.54

$0.00

189

454-15-0390.M4

04-0084

$65,186.06

$0.00

190

454-15-0391.M4

03-9076

$63,786.13

$0.00

191

454-15-0392.M4

04-1206

$97,876.74

$0.00

192

454-15-0393.M4

03-9462

$64,597.54

$0.00

193

454-15-0559.M4

05-8455

$22,835.70

$0.00

194

454-15-0560.M4

05-B628

$60,676.06

$0.00

195

454-15-0562.M4

06-2263

$76,350.99

$0.00

196

454-15-0563.M4

05-2671

$45,970.30

$0.00

197

454-15-0564.M4

05-5333

$26,069.48

$0.00

198

454-15-0566.M4

05-6932

$80,426.08

$0.00

199

454-15-0569.M4

05-2051

$75,077.40

$0.00

200

454-15-0571.M4

05-2669

$38,782.56

$0.00

201

454-15-0572.M4

05-2050

$67,003.09

$0.00

202

454-15-0598.M4

04-7891

$52,336.95

$0.00

203

454-15-0602.M4

04-5369

$111,690.85

$0.00

204

454-15-0708.M4

04-0263

$70,909.07

$0.00

205

454-15-0710.M4

06-2643

$16,288.50

$0.00

206

454-15-0712.M4

05-3533

$57,288.98

$0.00

207

454-15-0713.M4

04-A011

$19,643.29

$0.00

208

454-15-0715.M4

04-5685

$85,436.63

$0.00

209

454-15-0716.M4

04-6407

$57,615.46

$0.00

210

454-15-0718.M4

04-6331

$45,121.52

$0.00

211

454-12-2515.M4

06-5999

$11,588.00

$0.00

212

454-12-4717.M4

06-6813

$34,181.37

$0.00

213

454-12-5113.M4

04-4886

$52,702.34

$0.00

214

454-12-5429.M4

05-2357

$72,293.07

$0.00

ATTACHMENT 2

Page 7 of 13

NO ADDITIONAL REIMBURSEMENT OWED TO PROVIDER

NO.

SOAH Dkt. No.

MR No.

Carrier Payment

Additional Reimbursement Owed to Provider

215

454-12-5431.M4

05-6406

$4,410.00

$0.00

216

454-12-5563.M4

05-B068

$26,676.60

$0.00

217

454-12-5566.M4

05-9499

$45,668.83

$0.00

218

454-12-5568.M4

05-1381

$32,490.25

$0.00

219

454-12-5858.M4

05-2250

$15,447.50

$0.00

220

454-12-5859.M4

04-6132

$14,100.00

$0.00

221

454-12-5860.M4

05-A450

$63,647.62

$0.00

222

454-12-5861.M4

06-2054

$42,750.50

$0.00

223

454-12-5957.M4

06-6819

$3,840.50

$0.00

224

454-12-6021.M4

08-0068

$18,098.60

$0.00

225

454-12-6121.M4

05-8105

$14,012.52

$0.00

226

454-12-6572.M4

06-6235

$9,565.55

$0.00

227

454-12-7146.M4

03-7989

$48,246.68

$0.00

228

454-12-7149.M4

06-7060

$27,047.58

$0.00

229

454-12-7150.M4

06-6795

$2,678.00

$0.00

230

454-12-7313.M4

07-2867

$7,846.00

$0.00

231

454-12-7316.M4

07-0172

$11,206.50

$0.00

232

454-12-7320.M4

06-6826

$9,205.45

$0.00

233

454-12-7495.M4

04-6315

$35,859.80

$0.00

234

454-13-0108.M4

07-4151

$10,209.50

$0.00

235

454-13-0517.M4

09-6009

$22,982.00

$0.00

236

454-13-0518.M4

09-4686

$47,769.82

$0.00

237

454-13-0520.M4

07-0060

$30,551.50

$0.00

238

454-13-0521.M4

07-0600

$18,446.00

$0.00

239

454-13-0524.M4

06-6000

$2,236.00

$0.00

240

454-13-0526.M4

07-0601

$19,554.50

$0.00

241

454-13-0527.M4

07-1868

$9,648.00

$0.00

242

454-13-0529.M4

07-4151

See 454-13-0108.M4

$0.00

243

454-13-0531.M4

07-7038

$26,654.60

$0.00

244

454-13-0532.M4

08-0199

$20,943.60

$0.00

245

454-13-0896.M4

08-4985

$9,428.90

$0.00

246

454-13-1278.M4

09-6011

$9,401.00

$0.00

247

454-13-1408.M4

07-4026

$7,674.00

$0.00

248

454-13-1409.M4

07-0726

$26,131.00

$0.00

249

454-13-1410.M4

07-3130

$14,531.50

$0.00

250

454-13-1411.M4

08-1472

$6,486.00

$0.00

251

454-13-1412.M4

07-3222

$56,387.52

$0.00

ATTACHMENT 2

Page 8 of 13

NO ADDITIONAL REIMBURSEMENT OWED TO PROVIDER

NO.

SOAH Dkt. No.

MR No.

Carrier Payment

Additional Reimbursement Owed to Provider

252

454-13-1463.M4

07-4000

$13,255.80

$0.00

253

454-13-1464.M4

08-1294

$25,289.50

$0.00

254

454-13-1465.M4

07-3993

$42,779.70

$0.00

255

454-13-1466.M4

08-2803

$22,798.38

$0.00

256

454-13-1467.M4

07-4010

$36,766.50

$0.00

257

454-13-1468.M4

08-2804

$48,697.52

$0.00

258

454-13-1469.M4

07-3972

$9,131.50

$0.00

259

454-13-1470.M4

08-5039

$60,381.62

$0.00

260

454-13-1471.M4

08-1305

$2,236.00

$0.00

261

454-13-1472.M4

07-2077

$42,549.77

$0.00

262

454-13-1486.M4

06-2925

$41,488.40

$0.00

263

454-13-1492.M4

07-7022

$64,160.87

$0.00

264

454-13-1493.M4

07-7857

$65,949.39

$0.00

265

454-13-1540.M4

09-6031

$44,795.34

$0.00

266

454-13-1541.M4

08-1441

$8,106.70

$0.00

267

454-13-2121.M4

03-9084

$47,925.55

$0.00

268

454-13-2129.M4

07-1008

$26,822.00

$0.00

269

454-13-2130.M4

07-4044

$15,848.50

$0.00

270

454-13-2131.M4

08-6248

$24,032.30

$0.00

271

454-13-2176.M4

08-6247

$45,214.59

$0.00

272

454-13-2190.M4

03-8005

$32,735.40

$0.00

273

454-13-2432.M4

08-6161

$68,445.40

$0.00

274

454-13-2437.M4

08-2899

$62,642.74

$0.00

275

454-13-2452.M4

07-2180

$31,255.50

$0.00

276

454-13-2453.M4

08-1749

$18,567.00

$0.00

277

454-13-2455.M4

07-0728

$16,868.60

$0.00

278

454-13-2462.M4

08-1293

$21,434.50

$0.00

279

454-13-2463.M4

05-B592

$4,865.00

$0.00

280

454-13-2476.M4

06-6236

$3,840.50

$0.00

281

454-13-2477.M4

06-5234

$80,740.58

$0.00

282

454-13-2514.M4

07-3199

$40,813.00

$0.00

283

454-13-2866.M4

07-1012

$22,914.00

$0.00

284

454-13-2867.M4

07-0952

$26,997.00

$0.00

285

454-13-2868.M4

07-0091

$17,571.50

$0.00

286

454-13-3317.M4

07-3130

$16,962.80

$0.00

287

454-13-3325.M4

08-1472

$20,291.40

$0.00

288

454-13-3410.M4

07-3222

$22,434.03

$0.00

ATTACHMENT 2

Page 9 of 13

NO ADDITIONAL REIMBURSEMENT OWED TO PROVIDER

NO.

SOAH Dkt. No.

MR No.

Carrier Payment

Additional Reimbursement Owed to Provider

289

454-13-3687.M4

07-1591

$16,204.70

$0.00

290

454-13-3688.M4

08-4938

$55,749.95

$0.00

291

454-13-4271.M4

05-7994

$93,473.16

$0.00

292

454-13-4383.M4

04-7873

$39,128.79

$0.00

293

454-13-4437.M4

07-2705

$18,688.20

$0.00

294

454-13-4439.M4

07-4011

$17,899.16

$0.00

295

454-13-4450.M4

07-8009

$28,749.25

$0.00

296

454-13-4455.M4

08-1389

$48,977.21

$0.00

297

454-13-4456.M4

08-1659

$25,842.00

$0.00

298

454-13-4458.M4

08-4982

$87,802.47

$0.00

299

454-13-4460.M4

08-5430

$106,688.01

$0.00

300

454-13-4466.M4

09-6308

$27,825.50

$0.00

301

454-13-4577.M4

03-2855

$37,247.94

$0.00

302

454-13-5036.M4

06-5138

$15,740.06

$0.00

303

454-13-5130.M4

09-4878

$6,420.00

$0.00

304

454-13-5168.M4

05-8432

$52,032.96

$0.00

305

454-13-6110.M4

06-5310

$158,119.33

$0.00

306

454-14-0080.M4

07-7741

$77,669.77

$0.00

307

454-14-0081.M4

03-5858

$39,488.45

$0.00

308

454-14-0468.M4

07-8170

$4,032.73

$0.00

309

454-14-2363.M4

09-4874

$6,178.00

$0.00

310

454-14-2394.M4

07-6990

$20,653.00

$0.00

311

454-14-2858.M4

09-6270

$99,690.54

$0.00

312

454-15-1312.M4

07-4048

$63,713.75

$0.00

313

454-15-1316.M4

07-4629

$7,790.10

$0.00

314

454-15-1317.M4

07-8215

$15,817.00

$0.00

315

454-15-1319.M4

08-0064

$72,187.27

$0.00

316

454-15-1320.M4

08-0067

$19,146.00

$0.00

317

454-15-1330.M4

07-3992

$8,720.50

$0.00

318

454-15-1331.M4

07-2666

$21,669.00

$0.00

319

454-13-3314.M4

08-2856

$73,051.49

$0.00

320

454-13-1543.M4

06-2213

$24,843.40

$0.00

321

454-13-1487.M4

05-4623

$10,416.20

$0.00

322

454-13-2184.M4

07-8134

$10,803.50

$0.00

323

454-13-2423.M4

07-2127

$8,161.00

$0.00

324

454-13-2424.M4

06-0415

$18,459.68

$0.00

325

454-13-3679.M4

08-4935

$15,100.50

$0.00

ATTACHMENT 2

Page 10 of 13

NO ADDITIONAL REIMBURSEMENT OWED TO PROVIDER

NO.

SOAH Dkt. No.

MR No.

Carrier Payment

Additional Reimbursement Owed to Provider

326

454-13-4274.M4

07-4685

$18,720.55

$0.00

327

454-13-4376.M4

05-B242

$43,321.03

$0.00

328

454-13-4445.M4

07-7047

$25,093.00

$0.00

329

454-13-4447.M4

07-7417

$24,648.20

$0.00

330

454-13-4448.M4

07-7667

$28,285.00

$0.00

331

454-13-4449.M4

07-7742

$16,212.30

$0.00

332

454-13-5056.M4

03-3672

$89,142.76

$0.00

333

454-14-2860.M4

07-4122

$33,777.20

$0.00

334

454-15-1314.M4

03-A346

$70,802.57

$0.00

335

454-13-0988.M4

09-8055

$9,269.49

$0.00

336

454-13-2530.M4

08-7184

$3,365.95

$0.00

337

454-13-2965.M4

09-2649

$19,510.40

$0.00

338

454-13-2528.M4

08-5290

$28,248.61

$0.00

339

454-13-1106.M4

07-4485

$16,770.00

$0.00

340

454-13-2600.M4

09-3868

$12,645.96

$0.00

341

454-13-2969.M4

06-6108

$21,173.47

$0.00

342

454-13-2596.M4

09-2165

$10,705.10

$0.00

343

454-13-2597.M4

09-3854

$4,870.89

$0.00

344

454-13-2954.M4

09-0203

$91,706.70

$0.00

345

454-13-2956.M4

09-2863

$12,112.89

$0.00

346

454-13-4166.M4

07-4267

$46,647.30

$0.00

347

454-13-2963.M4

09-2681

$15,393.30

$0.00

348

454-13-5958.M4

08-4321

$8,622.60

$0.00

349

454-13-3798.M4

05-4612

$67,850.10

$0.00

350

454-13-3942.M4

08-4649

$23,275.00

$0.00

351

454-13-4019.M4

07-3229

$8,842.88

$0.00

352

454-13-4156.M4

08-1419

$4,243.70

$0.00

353

454-13-5234.M4

08-1628

$28,170.00

$0.00

354

454-13-5237.M4

07-0732

$10,271.50

$0.00

355

454-13-5238.M4

09-0032

$30,977.72

$0.00

356

454-12-0785.M4

04-6842

$22,275.38

$0.00

357

454-13-1265.M4

04-A430

$22,524.72

$0.00

358

454-13-1389.M4

06-4838

$26,489.12

$0.00

359

454-13-1804.M4

07-1386

$19,936.14

$0.00

360

454-13-1805.M4

06-6439

$10,308.53

$0.00

361

454-13-1818.M4

06-2572

$10,170.09

$0.00

362

454-13-1858.M4

07-5853

$11,616.78

$0.00

ATTACHMENT 2

Page 11 of 13

NO ADDITIONAL REIMBURSEMENT OWED TO PROVIDER

NO.

SOAH Dkt. No.

MR No.

Carrier Payment

Additional Reimbursement Owed to Provider

363

454-13-1875.M4

07-2005

$6,382.89

$0.00

364

454-13-2595.M4

07-5061

$9,062.15

$0.00

365

454-13-3422.M4

09-0147

$27,561.67

$0.00

366

454-13-3424.M4

04-A432

$15,927.40

$0.00

367

454-13-3425.M4

08-1539

$15,157.04

$0.00

368

454-13-3436.M4

07-5962

$18,945.30

$0.00

369

454-13-3464.M4

06-7434

$20,828.71

$0.00

370

454-13-3466.M4

08-6413

$8,708.76

$0.00

371

454-13-3467.M4

07-5070

$15,733.76

$0.00

382

454-13-3472.M4

06-7049

$14,091.86

$0.00

383

454-13-2523.M4

08-6662

$7,387.76

$0.00

384

454-13-4191.M4

07-0560

$18,009.91

$0.00

385

454-13-1874.M4

06-5355

$26,825.00

$0.00

386

454-13-2610.M4

08-0380

$17,502.06

$0.00

387

454-13-3469.M4

08-7134

$32,770.79

$0.00

388

454-13-3470.M4

07-8012

$9,878.14

$0.00

389

454-13-4701.M4

07-1731

$7,813.26

$0.00

390

454-12-0520.M4

04-2761

$112,561.36

$0.00

391

454-12-7498.M4

05-B550

$30,559.96

$0.00

392

454-12-7499.M4

06-2756

$7,836.57

$0.00

393

454-12-7508.M4

06.1375

$17,149.74

$0.00

394

454-12-7511.M4

05-1928

$5,106.67

$0.00

395

454-12-7512.M4

04-1493

$15,584.59

$0.00

396

454-12-7730.M4

04-B464

$44,456.53

$0.00

397

454-12-7744.M4

04-9796

$9,166.84

$0.00

398

454-12-7746.M4

05-0303

$30,911.39

$0.00

399

454-13-1268.M4

05-9198

$8,287.19

$0.00

400

454-13-1274.M4

07-1249

$11,582.77

$0.00

401

454-13-1384.M4

05-A343

$7,818.00

$0.00

402

454-13-1764.M4

08-6253

$10,396.20

$0.00

403

454-13-1844.M4

07-4938

$5,590.00

$0.00

404

454-13-1887.M4

08-2555

$5,631.76

$0.00

405

454-13-1888.M4

07-0578

$6,708.00

$0.00

406

454-13-3435.M4

06-3826

$30,773.13

$0.00

407

454-13-3439.M4

08-6253

$10,396.20

$0.00

408

454-13-3460.M4

08-2040

$13,880.00

$0.00

409

454-13-3555.M4

07-2414

$24,761.50

$0.00

ATTACHMENT 2

Page 12 of 13

NO ADDITIONAL REIMBURSEMENT OWED TO PROVIDER

NO.

SOAH Dkt. No.

MR No.

Carrier Payment

Additional Reimbursement Owed to Provider

410

454-13-3800.M4

08-0332

$16,034.41

$0.00

411

454-13-3805.M4

07-5509

$44,684.04

$0.00

412

454-13-4194.M4

05-5106

$11,647.32

$0.00

413

454-13-4637.M4

06-6838

$22,446.53

$0.00

414

454-13-4697.M4

08-2284

$10,737.89

$0.00

415

454-13-5585.M4

06-6838

See 454-13-4637.M4

See 454-13-4637.M4

416

454-13-4181.M4

07-6050

$39,299.96

$0.00

417

454-12-7500.M4

05-A362

$29,057.06

$0.00

418

454-12-7510.M4

06-4720

$6,700.05

$0.00

419

454-12-7513.M4

05-0798

$50,983.63

$0.00

420

454-12-7515.M4

05-3904

$36,542.42

$0.00

421

454-13-1842.M4

07-3139

$69,400.44

$0.00

422

454-13-1843.M4

07-3761

$64,131.32

$0.00

423

454-13-3551.M4

07-4555

$12,071.22

$0.00

424

454-13-3552.M4

07-3599

$9,333.75

$0.00

425

454-13-4193.M4

05-1926

$43,091.92

$0.00

426

454-13-4318.M4

07-0672

$57,363.70

$0.00

427

454-13-4330.M4

06-6523

$12,963.25

$0.00

428

454-13-4641.M4

06-7044

$23,630.32

$0.00

429

454-13-4643.M4

05-3214

$50,406.55

$0.00

430

454-13-4647.M4

06-7763

$8,784.78

$0.00

431

454-13-4695.M4

08-5593

$27,049.31

$0.00

432

454-13-4698.M4

06-5764

$11,446.21

$0.00

433

454-13-4706.M4

08-4751

$28,078.05

$0.00

434

454-13-4762.M4

04-7903

$47,297.26

$0.00

435

454-13-4763.M4

09-6007

$20,528.66

$0.00

436

454-13-1850.M4

06-3621

$13,773.19

$0.00

437

454-13-1851.M4

06-6520

$12,766.25

$0.00

438

454-13-1852.M4

05-6931

$9,523.55

$0.00

439

454-13-1854.M4

08-3458

$30,251.60

$0.00

440

454-13-1855.M4

08-2999

$15,636.20

$0.00

441

454-13-1856.M4

08-2041

$13,227.20

$0.00

442

454-13-1878.M4

09-0050

$36,655.63

$0.00

443

454-13-1879.M4

09-0049

$38,146.39

$0.00

444

454-13-2591.M4

08-4746

$11,693.06

$0.00

445

454-13-2606.M4

05-B502

$18,563.66

$0.00

446

454-13-3440.M4

08-7132

$7,461.00

$0.00

ATTACHMENT 2

Page 13 of 13

NO ADDITIONAL REIMBURSEMENT OWED TO PROVIDER

NO.

SOAH Dkt. No.

MR No.

Carrier Payment

Additional Reimbursement Owed to Provider

447

454-13-3471.M4

07-4384

$3,343.26

$0.00

448

454-13-3545.M4

07-5944

$3,527.70

$0.00

449

454-13-3547.M4

06-6830

$6,009.23

$0.00

450

454-13-3548.M4

08-5240

$7,314.00

$0.00

451

454-13-3560.M4

07-3678

$16,223.30

$0.00

452

454-13-4188.M4

06-4514

$9,393.53

$0.00

453

454-13-4189.M4

07-0920

$23,137.57

$0.00

454

454-13-4190.M4

05-2742

$58,362.59

$0.00

455

454-13-4195.M4

08-2226

$18,552.71

$0.00

456

454-13-4328.M4

06-2199

$27,167.67

$0.00

457

454-13-4329.M4

05-6894

$25,500.17

$0.00

458

454-13-4632.M4

07-5963

$15,757.88

$0.00

459

454-13-4633.M4

07-7231

$11,233.75

$0.00

460

454-13-4634.M4

07-6458

$1,118.00

$0.00

461

454-13-4700.M4

08-6310

$17,245.05

$0.00

ATTACHMENT 3

Page 1 of 2

CASE REIMBURSED UNDER PER DIEM METHODOLOGY

ADDITIONAL REIMBURSEMENT OWED PROVIDER

NO.

SOAH Dkt. No.

MR No.

Total Owed

Carrier Payment

Additional Reimbursement Owed to Provider

1

454-13-2443.M4

07-1614

$29,641.80

$27,257.00

$2,384.80

2

454-13-3303.M4

08-6241

$9,786.07

$9,032.57

$753.50

3

454-13-3307.M4

08-6160

$11,827.67

$11,075.16

$752.51

4

454-13-4444.M4

07-5512

$10,570.20

$8,650.70

$1,919.50

5

454-13-5035.M4

04-5349

$43,355.10

$36,647.10

$6,708.00

6

454-14-2861.M4

14-1733

$19,748.80

$15,681.00

$4,067.80

7

454-13-0604.M4

07-1490

$21,169.00

$17,843.00

$3,326.00

8

454-12-7446.M4

06-1461

$16,415.46

$13,980.70

$2,434.76

9

454-12-7452.M4

06-2973

$2,236.00

$0.00

$2,236.00

10

454-12-7518.M4

05-2655

$8,325.20

$2,889.30

$5,435.90

11

454-13-1122.M4

06-2142

$37,754.30

$19,161.00

$18,593.30

12

454-13-1254.M4

07-4131

$23,396.20

$18,778.30

$4,617.90

13

454-13-4367.M4

05-8699

$22,941.70

$22,817.40

$124.30

14

454-13-4443.M4

07-5436

$19,148.50

$18,395.00

$753.50

15

454-13-2446.M4

07-8177

$17,477.60

$17,365.60

$112.00

16

454-13-2461.M4

06-1406

$37,370.05

$26,263.50

$11,106.55

17

454-13-2466.M4

07-4012

$15,221.50

$15,133.50

$88.00

18

454-13-1542.M4

07-0575

$36,123.00

$13,210.00

$22,913.00

19

454-13-5126.M4

07-7344

$29,924.50

$28,170.50

$1,754.00

20

454-12-1961.M4

06-6001

$26,954.50

$3,354.00

$23,600.50

21

454-12-5500.M4

05-6722

$12,026.00

$11,594.69

$431.31

22

454-12-5565.M4

06-2096

$35,761.50

$30,987.00

$4,774.50

23

454-12-5569.M4

06-6231

$14,475.70

$6,945.10

$7,530.60

24

454-12-7312.M4

07-0731

$28,026.50

$27,836.50

$190.00

25

454-12-7333.M4

07-4046

$10,176.50

$1,118.00

$9,058.50

26

454-12-7838.M4

06-1611

$44,762.45

$38,571.13

$6,191.32

27

454-13-0105.M4

07-4673

$20,297.00

$18,812.00

$1,485.00

28

454-13-0106.M4

07-1021

$18,638.40

$17,538.40

$1,100.00

29

454-13-0107.M4

08-5035

$9,633.97

$2,236.00

$7,397.97

30

454-13-0140.M4

06-0659

$48,900.89

$40,157.00

$8,743.89

31

454-13-0525.M4

06-6004

$23,930.58

$18,267.78

$5,662.80

32

454-13-1406.M4

07-3984

$5,859.00

$3,659.00

$2,200.00

33

454-13-1407.M4

07-8133

$10,545.00

$9,648.50

$896.50

34

454-13-1491.M4

09-6427

$26,634.00

$22,809.30

$3,824.70

35

454-13-2141.M4

07-4673

See 454-13-0105.M4

See 454-13-0105.M4

See 454-13-0105.M4

ATTACHMENT 3

Page 2 of 2

CASE REIMBURSED UNDER PER DIEM METHODOLOGY

ADDITIONAL REIMBURSEMENT OWED PROVIDER

NO.

SOAH Dkt. No.

MR No.

Total Owed

Carrier Payment

Additional Reimbursement Owed to Provider

36

454-13-2541.M4

05-B563

$24,607.10

$23,936.10

$671.00

37

454-13-2723.M4

07-4046

See 454-12-7333.M4

See 454-12-7333.M4

See 454-12-7333.M4

38

454-13-2872.M4

06-1611

See 454 12-7838.M4

See 454 12-7838.M4

See 454 12-7838.M4

39

454-13-4377.M4

06-2094

$25,986.50

$23,594.00

$2,392.50

40

454-13-4446.M4

07-7388

$38,083.00

$34,783.00

$3,300.00

41

454-15-1333.M4

07-0122

$27,577.90

$27,090.50

$487.40

42

454-13-0522.M4

06-5151

$26,242.98

$20,754.00

$5,488.98

43

454-13-4382.M4

04-1365

$32,164.80

$2,236.00

$29,928.80

44

454-13-2957.M4

05-1635

$12,350.50

$7,325.01

$5,025.49

45

454-13-2529.M4

07-6767

$9,814.25

$0.00

$9,814.25

46

454-13-5957.M4

07-4250

$12,603.53

$11,401.23

$1,202.30

47

454-13-2527.M4

09-2100

$36,110.50

$2,236.00

$33,874.50

48

454-13-2967.M4

08-0921

$14,064.84

$13,773.60

$291.24

49

454-13-3803.M4

07-7937

$20,718.61

$19,487.98

$1,230.63

50

454-13-4029.M4

09-2859

$14,949.41

$5,590.00

$9,359.41

51

454-13-4153.M4

08-0968

$60,548.47

$60,317.37

$231.10

52

454-13-1806.M4

07-2097

$22,738.82

$22,386.15

$352.67

53

454-13-1807.M4

07-7244

$20,212.02

$15,974.02

$4,238.00

54

454-12-7710.M4

05-5106

$11,982.72

$11,647.32

$335.40

55

454-13-3804.M4

08-1048

$6,708.00

$3,354.00

$3,354.00

56

454-13-4642.M4

08-2140

$10,850.43

$10,469.38

$381.05

57

454-13-3559.M4

08-2269

$12,969.40

$11,851.40

$1,118.00

ATTACHMENT 4

Page 1 of 1

CASES THAT ARE EXCLUDED FROM PER DIEM/STOP-LOSS EXCEPTION

NO.

SOAH Dkt. No.

MR No.

Provider

Carrier

Type of Reimbursement

1

454-12-0230.M4

07-2681

Corpus Christi Medical Center

Texas Mutual Insurance Co.

Trauma-Fair & Reasonable

2

454-12-0231.M4

07-0774

Bayshore Medical Center Center

Texas Mutual Insurance Co.

Trauma-Fair & Reasonable

3

454-12-5958.M4

06-7047

Vista Medical Center Hospital

Commerce & Industry Insurance Co.

Trauma-Fair & Reasonable

4

454-13-1849.M4

09-3797

Christus St. Elizabeth Hospital

Zurich American Insurance Co.

Trauma-Fair & Reasonable

5

454-13-2533.M4

06-7290

Bayshore Medical Center Center

Texas Municipal League Intergovernmental Risk Pool

Trauma-Fair & Reasonable

6

454-13-3950.M4

08-4685

Park Plaza Hospital

Liberty Insurance Corporation

Rehab- Fair & Reasonable

7

454-13-4314.M4

06-0819

Texas Orthopedic Hospital

American Home Assurance Co.

Trauma-Fair & Reasonable

8

454-13-2607.M4

09-1348

Triumph Hospital El Paso

Liberty Insurance Corporation

Rehab- Fair & Reasonable

9

454-13-4192.M4

09-3479

Christus St. Elizabeth Hospital

Liberty Mutual Ins. Co.

Trauma-Fair & Reasonable

10

454-14-1564.M4

09-4193

Christus St. Elizabeth Hospital

Zurich American Insurance Co.

Trauma-Fair & Reasonable

  1. Effective September 1, 2005, the legislature dissolved the Texas Workers’ Compensation Commission (Commission) and created the Division of Workers’ Compensation within the Texas Department of Insurance. Act of June 1, 2005, 79th Leg., R.S., ch. 265, § 8.001, 2005 Tex. Gen. Laws 469, 607. This Decision and Order refers to the Commission and its successor collectively as the Division.
  2. The 1997 ACIHFG, originally codified at 28 Texas Administrative Code § 134.401 (Former Rule), established a general reimbursement scheme for all inpatient services provided by an acute care hospital for medical and/or surgical admissions using a service-related standard per diem amount. On a case-by-case basis, independent reimbursement is allowed if the particular case exceeds the Stop-Loss Threshold as described in paragraph (6) of Former Rule 134.401(c). This independent reimbursement mechanism, the Stop-Loss Method or Stop-Loss Methodology, is sometimes referred to as the Stop-Loss Exception or the Stop-Loss Rule.
  3. A large number of cases were referred to the State Office of Administrative Hearings (SOAH) too late to be included in the consolidated and joined hearing dockets. Those cases remain pending at SOAH for hearing assignment by ALJ Card. Several cases in the hearing docket were abated or continued at the request of the parties and will be transferred to ALJ Card for additional proceedings.
  4. Tex. Lab. Code § 401.011(19) and (31). The Texas Workers’ Compensation Act is found at Texas Labor Code chapters 401‑419 (the Act).
  5. Act § 413.011(d).
  6. Id.
  7. Id.
  8. 22 TexReg 6305, 6306 (July 4, 1997).
  9. 28 Tex. Admin. Code § 134.404(a)(2). See 33 TexReg 5319 (July 4, 2008).
  10. The “Standard Per Diem Amount” was $870 for a medical admission, $1,118 for a surgical admission, and $1,560 for an Intensive Care Unit (ICU)/Cardiac Care Unit (CCU) stay. Former Rule 134.401(c)(1). When the injured worker’s admission was a medical admission but surgery was subsequently performed during the stay, the entire stay was considered a surgical admission. Former Rule 134.401(b)(2)(F). For each day the injured worker was in the ICU or CCU, the ICU/CCU per diem reimbursement rate was paid in lieu of the medical or surgical per diem rate. Former Rule 134.401(c)(2)(B).
  11. Former Rule 134.401(c)(4).
  12. Former Rule 134.401(c)(4)(A)(i-ii).
  13. Former Rule 134.401(c)(4)(C).
  14. Former Rule 134.401(c)(4)(B)(i).
  15. Former Rule 134.401(c)(4)(B)(ii).
  16. Former Rule 134.401(c)(4)(B)(iii).
  17. Former Rule 134.401(c)(4)(B)(iv).
  18. Former Rule 134.401(c)(4)(B)(v).
  19. Former Rule 134.401(c). ICD-9 is The International Statistical Classification of Diseases, ninth revision.
  20. Former Rule 134.401(c)(6).
  21. Former Rule 134.401(c)(6)(A)(i). The Former Rule defined “Stop-Loss Threshold (SLT)” as follows:
  22. Threshold of total charges established by the Commission, beyond which reimbursement is calculated by multiplying the applicable Stop-Loss Reimbursement Factor by the total charges identifying that particular threshold.

    Former Rule 134.401(b)(1)(H).

  23. Former Rule 134.401(b)(2)(A).
  24. Vista I at 551.
  25. Vista I at 554.
  26. Vista I at 554.
  27. A diagnosis-related group is a patient classification system that standardizes prospective payment to hospitals. In general, a DRG payment covers all charges associated with an inpatient stay from the time of admission to discharge.
  28. Vista I at 554.
  29. Centers for Medicare & Medicaid Services.
End of Document
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