{"reporting_entity_name":"Allegiance Benefit Plan Mgmt","reporting_entity_type":"third party","last_updated_on":"2026-09-30","version":"2.0.0","out_of_network":[{"name":"Rx mbr clms - with stop loss","billing_code_type":"HCPCS","billing_code":"RXCPY","billing_code_type_version":"2026","description":"Rx mbr clms - with stop loss","allowed_amounts":[{"tin":{"type":"npi","value":"591031071"},"service_code":["*P"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":5.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":5.00,"npi":[]}]},{"allowed_amount":10.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":10.00,"npi":[]}]},{"allowed_amount":20.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":20.00,"npi":[]}]},{"allowed_amount":40.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":40.00,"npi":[]}]}]}]}]}