{"reporting_entity_name":"Northwest Administrators Inc.","reporting_entity_type":"Third Party","plan_id_type":"ein","plan_name":"Western Teamsters Welfare Trust","plan_id":"916033601","plan_market_type":"group","last_updated_on":"2026-10-20","version":"1.0.0.0","out_of_network":[{"name":"Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80307","description":"Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service","allowed_amounts":[{"tin":{"type":"ein","value":"813115799"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":300.00,"providers":[{"billed_charge":2485.20,"npi":[1306381694]}]},{"allowed_amount":2485.20,"providers":[{"billed_charge":2485.20,"npi":[1306381694]}]}]},{"tin":{"type":"ein","value":"843172409"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":4198.40,"npi":[1003437500]}]}]},{"tin":{"type":"ein","value":"541882269"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":345.00,"providers":[{"billed_charge":345.00,"npi":[1912903717]}]}]}]},{"name":"Chiropractic manipulative treatment (CMT); spinal, 3-4 regions","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"98941","description":"Chiropractic manipulative treatment (CMT); spinal, 3-4 regions","allowed_amounts":[{"tin":{"type":"ein","value":"473114123"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":94.00,"providers":[{"billed_charge":94.00,"npi":[1790021756]}]}]},{"tin":{"type":"ein","value":"473968270"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":60.00,"providers":[{"billed_charge":60.00,"npi":[1871965350]}]}]},{"tin":{"type":"ein","value":"352925148"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":77.00,"providers":[{"billed_charge":77.00,"npi":[1033986864]}]}]},{"tin":{"type":"ein","value":"262169481"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":65.00,"providers":[{"billed_charge":65.00,"npi":[1134211535]}]}]},{"tin":{"type":"ein","value":"943376854"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":60.00,"providers":[{"billed_charge":60.00,"npi":[1538246186]}]}]}]},{"name":"Mental health partial hospitalization, treatment, less than 24 hours (Not payable by Medicare)","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"H0035","description":"Mental health partial hospitalization, treatment, less than 24 hours (Not payable by Medicare)","allowed_amounts":[{"tin":{"type":"ein","value":"921808364"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":104.55,"providers":[{"billed_charge":6800.00,"npi":[1295449064]}]}]}]},{"name":"Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"G0481","description":"Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed","allowed_amounts":[{"tin":{"type":"ein","value":"813115799"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":1780.90,"npi":[1306381694]}]},{"allowed_amount":1241.35,"providers":[{"billed_charge":1780.90,"npi":[1306381694]}]},{"allowed_amount":1251.43,"providers":[{"billed_charge":1780.90,"npi":[1306381694]}]}]},{"tin":{"type":"ein","value":"912180910"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":156.59,"providers":[{"billed_charge":156.59,"npi":[1821092297]}]}]},{"tin":{"type":"ein","value":"463908799"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":165.00,"providers":[{"billed_charge":165.00,"npi":[1093136418]}]}]}]},{"name":"Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"97110","description":"Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility","allowed_amounts":[{"tin":{"type":"ein","value":"934053204"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":70.00,"providers":[{"billed_charge":70.00,"npi":[1962775346]}]}]},{"tin":{"type":"ein","value":"204818161"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":300.00,"providers":[{"billed_charge":300.00,"npi":[1649292608]}]},{"allowed_amount":320.00,"providers":[{"billed_charge":320.00,"npi":[1649292608]}]}]},{"tin":{"type":"ein","value":"826785205"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":60.00,"providers":[{"billed_charge":60.00,"npi":[1730196569]}]}]},{"tin":{"type":"ein","value":"352925148"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":40.00,"providers":[{"billed_charge":40.00,"npi":[1033986864]}]}]},{"tin":{"type":"ein","value":"270437769"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":75.00,"providers":[{"billed_charge":75.00,"npi":[1396826673]}]}]},{"tin":{"type":"ein","value":"911928166"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":171.60,"providers":[{"billed_charge":171.60,"npi":[1639032089]}]}]}]},{"name":"Chiropractic manipulative treatment (CMT); spinal, 1-2 regions","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"98940","description":"Chiropractic manipulative treatment (CMT); spinal, 1-2 regions","allowed_amounts":[{"tin":{"type":"ein","value":"473968270"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":60.00,"providers":[{"billed_charge":60.00,"npi":[1871965350]}]}]},{"tin":{"type":"ein","value":"204818161"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":85.00,"providers":[{"billed_charge":85.00,"npi":[1649292608]}]}]},{"tin":{"type":"ein","value":"524867886"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":60.00,"providers":[{"billed_charge":60.00,"npi":[1366509549]}]}]},{"tin":{"type":"ein","value":"831789860"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":60.00,"providers":[{"billed_charge":60.00,"npi":[1871800383]}]}]},{"tin":{"type":"npi","value":"1366509549"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":60.00,"providers":[{"billed_charge":60.00,"npi":[1366509549]}]}]},{"tin":{"type":"ein","value":"270437769"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":100.00,"providers":[{"billed_charge":100.00,"npi":[1396826673]}]}]}]}]}