Pruebas de Cernimiento del Virus de Inmunodeficiencia Humana (VIH)

ESTADO LIBRE ASOCIADO DE PUERTO RICO OFICINA DEL COMISIONADO DE SEGUROS 4 de septiembre de 2015 CARTA CIRCULAR NÚM.: CC-2015-1865-ES A TODOS LOS ASEGURADORES AUTORIZADOS A SUSCRIBIR SEGUROS DE SALUD Y A LAS ORGANIZACIONES DE SERVICIOS DE SALUD QUE SUSCRIBEN PLANES DE CUIDADO DE SALUD EN PUERTO RICO Pruebas de Cernimiento del Virus de Inmunodeficiencia Humana (VIH) Estimadas señoras y señores: A tenor con el Artículo 2.050(C)(1) del Código de Seguros de Salud de Puerto Rico todo asegurador u organización de seguros de salud que provea planes médicos individuales o grupales deben proveer cubierta con respecto a los servicios preventivos incluidos en las recomendaciones más recientes del "United States Preventive Services Task Force (USPSTF)". En aras de fiscalizar adecuadamente su cumplimiento, todo asegurador y organización de seguros de salud, presentará semestralmente ante nuestra Oficina, los formularios del "Report of HIV Tests", que se incluyen como anejos a esta carta circular. Los mismos deben incluir el número de pruebas y cantidad pagada por cada uno de los códigos y diagnósticos incluidos en los formularios, estos serán a su vez clasificados por fecha de servicios y edad del asegurado. Deberá incluir, además, la cantidad de facturas denegadas y sus códigos de denegación. En este primer año, los formularios incluyen información relacionada a servicios ofrecidos desde el 1 de enero de 2013 hasta el 30 de agosto de 2015 y serán presentados en o antes del 17 de septiembre de 2015. Mientras que en los años subsiguientes, la fecha de presentación del primer semestre será el 1 de septiembre y la fecha de presentación del segundo semestre será el 1 de marzo de cada año. Se deberá entregar una copia firmada en original de los formularios y una copia en formato electrónico (un B5 Calle Tabonuco Suite 216 • PMB 356 • Guaynabo, PR 00968-3029 • Tel: (787) 304-8686 • Fax: (787) 273-6082 www.ocs.gobierno.pr 2 CD utilizando Microsoft Excel). Todo informe provisto en una forma o formato diferente a los aquí requeridos, será considerado por esta Oficina como no presentado. Se requiere, por la presente, estricto cumplimiento con las disposiciones de esta Carta Circular. Cordialmente, Lcdo. Edward Rivera Maldonado Comisionado Auxiliar de Servicios Anejos OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ### REPORT OF HIV TESTS ### DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ ICD-9-CM Diagnosis - V65.44 Part I | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | 86689 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 86701 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 86703 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 97534 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 87535 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | Form-OCS-ES-2015-001 1 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO # REPORT OF HIV TESTS # DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ ICD-9-CM Diagnosis - V65.44 Part II | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | | 87536 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 87390 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 36415 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99385 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99386 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99395 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | Form-OCS-ES-2015-001 2 Sdlaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ### REPORT OF HIV TESTS ### DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ ICD-9-CM Diagnosis - V65.44 Part III | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | | 99211 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99215 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced Causes | | January | February | March | April | May | June | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official E-mail Name and Position of Official Signing Above Phone Number Form-OCS-ES-2015-001 3 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ## REPORT OF HIV TESTS ### DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ Medicare HCPCS - V08 | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | G0432 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0433 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0435 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced | | January | February | March | April | May | June | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official Name and Position of Official Signing Above E-mail Phone Number Form-OCS-ES-2015-006 14 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ### REPORT OF HIV TESTS ### DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ Medicare HCPCS - V042 | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | G0432 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0433 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0435 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced | | January | February | March | April | May | June | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official Name and Position of Official Signing Above E-mail Phone Number Form-OCS-ES-2015-007 15 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ## REPORT OF HIV TESTS ### DURING FIRST SEMESTER YEAR 20__ Company Name: ________________________ Naic Code: ________________________ Medicare HCPCS - V65.44 | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | G0432 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0433 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0435 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced | | January | February | March | April | May | June | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official Name and Position of Official Signing Above E-mail Phone Number Form-OCS-ES-2015-008 16 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ### REPORT OF HIV TESTS ### DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ Medicare HCPCS - V73.89 | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | G0432 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0433 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0435 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced | | January | February | March | April | May | June | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official Name and Position of Official Signing Above E-mail Phone Number Form-OCS-ES-2015-009 17 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ## REPORT OF HIV TESTS ### DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ Medicare HCPCS - V22.0 | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | G0432 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0433 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0435 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced | | January | February | March | April | May | June | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official Name and Position of Official Signing Above E-mail Phone Number Form-OCS-ES-2015-010 18 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO # REPORT OF HIV TESTS # DURING FIRST SEMESTER YEAR 20__ Company Name: Naic Code: Medicare HCPCS - V22.1 | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | G0432 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0433 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0435 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced | | January | February | March | April | May | June | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official Name and Position of Official Signing Above E-mail Phone Number Form-OCS-ES-2015-011 19 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ### REPORT OF HIV TESTS ### DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ Medicare HCPCS - V23.8 | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | G0432 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0433 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0435 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced | | January | February | March | April | May | June | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official Name and Position of Official Signing Above E-mail Phone Number Form-OCS-ES-2015-012 20 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ### REPORT OF HIV TESTS ### DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ Medicare HCPCS - V23.9 | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | G0432 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0433 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0435 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced | | January | February | March | April | May | June | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official Name and Position of Official Signing Above E-mail Phone Number Form-OCS-ES-2015-013 21 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ### REPORT OF HIV TESTS ### DURING SECOND SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ ICD-9-CM Diagnosis - V65.44 Part I | CPT | Age | July | | August | | September | | October | | November | | December | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | 86689 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 86701 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 86703 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 97534 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 87535 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | Form-OCS-ES-2015-014 22 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO REPORT OF HIV TESTS DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ ICD-9-CM Diagnosis - V65.44 Part II | CPT | Age | July | | August | | September | | October | | November | | December | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | | 87536 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 87390 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 36415 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99385 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99386 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99395 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | Form-OCS-ES-2015-014 23 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO REPORT OF HIV TESTS DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ ICD-9-CM Diagnosis - V65.44 Part III | CPT | Age | July | | August | | September | | October | | November | | December | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | | 99211 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99215 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced Causes | | January | February | March | April | May | June | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official E-mail Name and Position of Official Signing Above Phone Number Form-OCS-ES-2015-014 24 Sdlaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO REPORT OF HIV TESTS DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ ICD-9-CM Diagnosis - V69.8 Part II | CPT | Age | July | | August | | September | | October | | November | | December | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | | 87536 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 87390 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 36415 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99385 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99386 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99395 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | Form-OCS-ES-2015-015 26 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO REPORT OF HIV TESTS DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ ICD-9-CM Diagnosis - V69.8 Part III | CPT | Age | July | | August | | September | | October | | November | | December | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | | 99211 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99215 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced Causes | | January | February | March | April | May | June | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official E-mail Name and Position of Official Signing Above Phone Number Form-OCS-ES-2015-015 27 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO REPORT OF HIV TESTS DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ ICD-9-CM Diagnosis - V73.80 Part II | CPT | Age | July | | August | | September | | October | | November | | December | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | | 87536 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 87390 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 36415 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99385 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99386 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99395 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | Form-OCS-ES-2015-016 29 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO REPORT OF HIV TESTS DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ ICD-9-CM Diagnosis - V73.80 Part III | CPT | Age | July | | August | | September | | October | | November | | December | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | | 99211 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99215 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced Causes | | January | February | March | April | May | June | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official Name and Position of Official Signing Above E-mail Phone Number Form-OCS-ES-2015-016 30 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO REPORT OF HIV TESTS DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ ICD-9-CM Diagnosis - V70.0 Part II | CPT | Age | July | | August | | September | | October | | November | | December | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | | 87536 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 87390 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 36415 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99385 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99386 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99395 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | Form-OCS-ES-2015-017 32 Sdlaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO REPORT OF HIV TESTS DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Nale Code: _________________________ ICD-9-CM Diagnosis - V70.0 Part III | CPT | Age | July | | August | | September | | October | | November | | December | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | | 99211 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99215 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced Causes | | January | February | March | April | May | June | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official Name and Position of Official Signing Above E-mail Phone Number Form-OCS-ES-2015-017 33 Sdlaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ## REPORT OF HIV TESTS ### DURING SECOND SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ Medicare HCPCS - V08 | CPT | Age | July | | August | | September | | October | | November | | December | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | G0432 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0433 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0435 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced | | July | August | September | October | November | December | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official Name and Position of Official Signing Above E-mail Phone Number Form-OCS-ES-2015-019 35 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ### REPORT OF HIV TESTS ### DURING SECOND SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ Medicare HCPCS - V042 | CPT | Age | July | | August | | September | | October | | November | | December | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | G0432 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0433 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0435 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced | | July | August | September | October | November | December | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official Name and Position of Official Signing Above E-mail Phone Number Form-OCS-ES-2015-020 36 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ### REPORT OF HIV TESTS ### DURING SECOND SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ Medicare HCPCS - V65.44 | CPT | Age | July | | August | | September | | October | | November | | December | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | G0432 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0433 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0435 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced | | July | August | September | October | November | December | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official Name and Position of Official Signing Above E-mail Phone Number Form-OCS-ES-2015-021 37 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ## REPORT OF HIV TESTS ### DURING SECOND SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ Medicare HCPCS - V73.89 | CPT | Age | July | | August | | September | | October | | November | | December | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | G0432 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0433 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0435 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced | | July | August | September | October | November | December | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official Name and Position of Official Signing Above E-mail Phone Number Form-OCS-ES-2015-022 38 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ### REPORT OF HIV TESTS ### DURING SECOND SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ Medicare HCPCS - V22.0 | CPT | Age | July | | August | | September | | October | | November | | December | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | G0432 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0433 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0435 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced | | July | August | September | October | November | December | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official E-mail Name and Position of Official Signing Above Phone Number Form-OCS-ES-2015-023 39 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ### REPORT OF HIV TESTS ### DURING SECOND SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ Medicare HCPCS - V22.0 | CPT | Age | July | | August | | September | | October | | November | | December | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | G0432 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0433 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0435 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced | | July | August | September | October | November | December | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official Name and Position of Official Signing Above E-mail Phone Number Form-OCS-ES-2015-024 40 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ## REPORT OF HIV TESTS ### DURING SECOND SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ Medicare HCPCS - V23.8 | CPT | Age | July | | August | | September | | October | | November | | December | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | G0432 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0433 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0435 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced | | July | August | September | October | November | December | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official Name and Position of Official Signing Above E-mail Phone Number Form-OCS-ES-2015-025 41 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ## REPORT OF HIV TESTS ### DURING SECOND SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ Medicare HCPCS - V23.9 | CPT | Age | July | | August | | September | | October | | November | | December | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | G0432 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0433 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0435 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced | | July | August | September | October | November | December | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official Name and Position of Official Signing Above E-mail Phone Number Form-OCS-ES-2015-026 42 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ### REPORT OF HIV TESTS ### DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ ICD-9-CM Diagnosis - V69.8 Part I | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | 86689 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 86701 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 86703 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 97534 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 87535 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | Form-OCS-ES-2015-002 4 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO # REPORT OF HIV TESTS # DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ ICD-9-CM Diagnosis - V69.8 Part II | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | | 87536 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 87390 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 36415 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99385 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99386 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99395 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | Form-OCS-ES-2015-002 5 Sdlaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ### REPORT OF HIV TESTS ### DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ ICD-9-CM Diagnosis - V73.89 Part I | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | 86689 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 86701 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 86703 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 97534 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 87535 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | Form-OCS-ES-2015-003 7 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ### REPORT OF HIV TESTS ### DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ ICD-9-CM Diagnosis - V69.8 Part III | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | | 99211 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99215 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced Causes | | January | February | March | April | May | June | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official E-mail Name and Position of Official Signing Above Phone Number Form-OCS-ES-2015-002 6 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ### REPORT OF HIV TESTS ### DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ ICD-9-CM Diagnosis - V73.89 Part III | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | | 99211 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99215 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced Causes | | January | February | March | April | May | June | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official E-mail Name and Position of Official Signing Above Phone Number Form-OCS-ES-2015-003 9 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO # REPORT OF HIV TESTS # DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ ICD-9-CM Diagnosis - V70.0 Part II | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | | 87536 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 87390 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 36415 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99385 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99386 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99395 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | Form-OCS-ES-2015-004 11 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ### REPORT OF HIV TESTS ### DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ ICD-9-CM Diagnosis - V70.0 Part III | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | Number of Tests | Invoiced Payment | | 99211 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | 99215 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced Causes | | January | February | March | April | May | June | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official E-mail Name and Position of Official Signing Above Phone Number Form-OCS-ES-2015-004 12 Sdiaz OFFICE OF THE COMMISSIONER OF INSURANCE OF PUERTO RICO ### REPORT OF HIV TESTS ### DURING FIRST SEMESTER YEAR 20__ Company Name: _________________________ Naic Code: _________________________ Medicare HCPCS - V 65.44 | CPT | Age | January | | February | | March | | April | | May | | June | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Number of Test | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Test | Invoiced Pay | Number of Tests | Invoiced Pay | Number of Tests | Invoiced Pay | | G0432 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0433 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | G0435 | 14 to 17 Years | | | | | | | | | | | | | | | 18 to 24 Years | | | | | | | | | | | | | | | 25 to 44 Years | | | | | | | | | | | | | | | 45 to 64 Years | | | | | | | | | | | | | | Number of Unauthorized Invoiced in the month | | | | | | | | | | | | | | | Unauthorized Invoiced | | January | February | March | April | May | June | | --- | --- | --- | --- | --- | --- | --- | --- | | Code | 1 | | | | | | | | | 2 | | | | | | | | | 3 | | | | | | | | | 4 | | | | | | | | | 5 | | | | | | | Signature of Authorized Official Name and Position of Official Signing Above E-mail Phone Number Form-OCS-ES-2015-005 13 Sdiaz