November 17, 2021
PARA
WeeklyeJOURNAL NEWS FOR HEALTHCARE DECISION MAKERS
PAMA Reporting FAQs
Updated COVID Vaccine
For Acquir ed Labs Page 17
Pr oduct and Administr ation Codes
2 MedLear ns
17 Tr ansmittal s
- OIG Wor k plan : M et h od II CAH Pr o Fee Dou ble Billin g - PARA Year-End HCPCS Update Process - 2022 Codin g Updat e Docu m en t s Available - CMS Releases No Surprise Act -- Part II - No Su r pr ise Act Dispu t ed
- 2022 OPPS Update: Inpatient Only List Additions - OIG Wor k plan : Au dit Of ED Pr of ession al E/ M Ch ar ges - New And Revised Place Of Service Codes For Telehealth
- Administration: Pages 1-44 - HIM /Coding Staff: Pages 1-44 - Providers: Pages 2,7,12,17,18,19,21,22,25,34 - COVID Guidance: Pages 2,20,21 - Pharmacy: Page 2 1 - CAHs: Page 7
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Endocrinology: Page 34 Compliance: Pages 10,12,17 Inpatient Svcs: Page 13 Telehealth: Pages 11,30 DM E: Page 22 Critical Care: Page 22 Therapy Services: Page 25
© PARA Healt h Car e An alyt ics an HFRI Company CPT® is a r egist er ed t r adem ar k of t h e Am er ican M edical Associat ion
PARA Weekly eJournal: November 17, 2021
COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES In Special Edition 2021 CPT® Assistant Guides in September and October, the AMA CPT® Editorial Panel announced additional COVID-19 vaccine product and administration codes, including codes for the pediatric dose of Pfizer.Some codes assigned will become effective upon receiving FDA approval. The COVID-19 coding updates are provided on the following pages. (New codes are in red font).
Ref or m u lat ed Pf izer Vaccin e For Pediat r ic Use*
*For patients ages 5 through 11- requires reconstitution using a diluent to administer the appropriate dosage.The second dose should be administered at least 21 days following the first dose.
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PARA Weekly eJournal: November 17, 2021
COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES
Pf izer COVID-19 Vaccin e (or igin al ph osph at e bu f f er ) An d Adm in ist r at ion Codes
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PARA Weekly eJournal: November 17, 2021
COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES
Pf izer COVID-19 Tr is-su cr ose Bu f f er (Ready-To-Use) Vaccin e An d Adm in ist r at ion Codes
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PARA Weekly eJournal: November 17, 2021
COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES
M oder n a Vaccin es
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PARA Weekly eJournal: November 17, 2021
COVID-19 VACCINE PRODUCT & ADMINISTRATION CODES
Joh n son & Joh n son (Jan ssen ) Vaccin es
The AMA website publishing these codes is available at: https://www.ama-assn.org/practice-management/cpt/covid-19-cpt-vaccine-and-immunization-codes
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PARA Weekly eJournal: November 17, 2021
OIG WORKPLAN: METHOD II CAH PRO FEE DOUBLE-BILLING
The HHS Office of the Inspector General will issue a report in 2022 examining whether professional fees
billed on a facility claim by a Method II Critical Access Hospital may have also been separately submitted for reimbursement on a CMS 1500/837i claim, resulting in double-payment. A link and a summary of the audit is provided below: https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000574.asp
?Under Section 1834(g)(1) of the Social Security Act and Federal regulations (42 CFR §§ 410.152(k) and 413.70(b)), Critical Access Hospitals (CAHs) are paid under the Standard Payment Method unless they elect to be paid under the Optional (Elective) Payment Method. Under Section 1834(g)(2) of the Social Security Act and Federal regulation (42 CFR § 413.70(b)(3)(i)), a CAH may elect the Optional (Elective) Payment Method, under which it bills the Part B Medicare Administrative Contractor (MAC) for both Medicare Part B facility services and Medicare Part B professional services for its outpatients. If a physician or other practitioner reassigns his or her Medicare Part B billing rights pursuant to 42 CFR part 424, subpart F, and agrees to be included under a CAH's Optional (Elective) Payment Method, he or she must not bill the MAC for any outpatient professional services furnished at the CAH once the reassignment becomes effective. The CAH must forward a copy of the completed assignment form (Form CMS 855R) to the MAC and keep the original form on file. Each practitioner must sign an attestation that clearly states that he or she will not bill Medicare Part B for any services furnished in the CAH outpatient department once the reassignment has been given to the CAH (Medicare Claims Processing Manual, Chapter 4, Section 250.2). We will determine whether CAHs forwarded a completed Form CMS 855R to the MAC. We will determine whether both the CAH and physician billed and were paid by the MAC for the same outpatient professional services. We will determine whether the beneficiary paid coinsurance amounts to both the CAH and physician or other practitioner. We will also determine whether CMS has an edit in place to ensure that duplicate payments for beneficiary outpatient professional services are not made.?
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PARA Weekly eJournal: November 17, 2021
PARA YEAR-END HCPCS UPDATE PROCESS
PARA clien t s w ill be f u lly su ppor t ed w it h in f or m at ion an d assist an ce on t h e an n u al CPT® HCPCS codin g u pdat es f or calen dar year 2022. The PARA Data Editor (PDE) contains a copy of each client chargemaster. We use the powerful features of the PDE to identify any line item in the chargemaster which has a HCPCS code assigned that will be deleted as of December 31, 2021. It is important that clients check to ensure that a recent copy of the chargemaster has been supplied to PARA for use in the year-end update. PARA will produce excel spreadsheets of each CDM line item, as well as our recommendation for alternate codes, in three waves as information is released from the following sources: - The American Medical Association?s publication of new, changed, and deleted CPT® codes. This information is released in September of each year. PARA will produce the first spreadsheet of CPT® updates for client review in October 2021. - Following the release of Medicare?s 2022 OPPS Final Rule, typically in early November; PARA will perform an analysis and produce the second spreadsheet to include both the CPT® information previously supplied, as well as alpha-numeric HCPCS updates (J-codes, G-codes, C-codes, etc.) from the Final Rule. Clients may expect this spreadsheet to be available in November 2021. - Following the publication of Medicare?s 2022 Clinical Lab Fee Schedule (CLFS), typically released in late November, PARA will prepare a final spreadsheet to be available in December 2021. This final spreadsheet ensures that PARA shares any late-breaking news or coding information, although we expect the December spreadsheet to be very similar to the November edition. Clients will be notified by email as spreadsheets are produced and recorded on the PARA Data Editor ?Admin? tab, under the ?Docs? sub tab. The spreadsheet will appear as shown below:
In addition, PARA consultants will publish concise papers on coding update topics to ensure that topical information is available in a manner that is organized and easy to understand. PARA clients may rest assured that they will have full support for year-end HCPCS coding updates to the chargemaster.
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PARA Weekly eJournal: November 17, 2021
2022 CODING UPDATE DOCUMENTS AVAILABLE
In preparation for the year-end CPT®/HCPCS update, PARA has prepared several brief ?2022 Coding Update? documents listing deleted codes and possible replacement codes within a particular clinical area or procedure group. The documents are available on the PARA Data Editor ?Advisor? tab. The individual coding topics addressed do not encompass all CPT® updates, only those which are most likely to be ?hard-coded? to a line item in a facility chargemaster. Topics are divided into immediately related areas, and more than one paper may contain information useful to a service line manager. In addition, the list of all CPT® codes that will be deleted in 2022 is also available. Due to CPT® licensing restrictions, these documents cannot be published within the PARA Weekly eJournal. PARA Data Editor users may access the information on the Advisor tab; search ?Coding Update? in the type field, and/or 2022 in the subject field, as illustrated below:
Provisional Medicare reimbursement information is offered in keeping with the 2022 OPPS Proposed Rule. Following the release of the OPPS Final Rule (typically published in early November), coding update papers will be revised to indicate with certainty whether Medicare will accept/cover the new codes.If changes are made to the coding update papers, readers can identify new versions the word ?Revised? in the title, and the date issued will be updated ? the hyperlink to the paper will remain identical to the original hyperlink, when an updated version is produced.
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PARA Weekly eJournal: November 17, 2021
CMS RELEASES NO SURPRISES ACT -- PART II
On September 30, 2021, the Department of Health and Human Services (HHS), the Department of Labor and the Department of Treasury released Part II of the No Surprises Act. The Act, which goes into effect on January 1, 2022, aims to protect patients from unexpected out of pocket costs resulting from surprise and balance billing. Part II of the Act addresses plan coverage requirements, independent dispute resolution processes between the payers and providers, and details for how payers will determine patient cost-sharing responsibilities. The unpublished rule, which will be published on October 7, 2021, can be accessed through the Federal Register website: https://www.federalregister.gov/public-inspection/2021-21441/requirements-related-tosurprise-billing-part-ii
CMS devotes a website to the No Surprises Act: https://www.cms.gov/nosurprises
CMS Fact Sheet ? No Surprises Act, Part I: https://www.cms.gov/newsroom/fact-sheets/ requirements-related-surprise-billingpart-i-interim-final-rule-comment-period CMS Fact Sheet ? No Surprises Act, Part II: https://www.cms.gov/newsroom/fact-sheets/ requirements-related-surprise-billing-part-ii -interim-final-rule-comment-period 10
PARA Weekly eJournal: November 17, 2021
NO SURPRISES PART II DISPUTED PAYMENT REGS CRITICIZED
Several members of the US House of Representatives are circulating a draft letter criticizing the ?No Surprises Part II?regulations pertaining to provisions for Independent Dispute Resolution (IDR.) Part II of the regulations implementing the No Surprise Act were released on September 30, 2021; due to the need to implement regulations before January 1, they have been released as an Interim Final Rule (IFR). Part II of the regulations address the means by which the Independent Dispute Resolution process willdetermine the appropriate value of out-of-network services rendered to insured patients in emergencies or in cases where an out-of-network provider, such as an anesthesiologist or radiologist, renders care for a non-emergent service at an in-network facility.The valuation relies heavily on the insurer?s ?median in-network rate.?The Representatives have expressed concern that this provision within the IDR process sets providers at a marked disadvantage. U.S. Reps. Tom Suozzi (D-N.Y.) and Brad Wenstrup (R-Ohio) are seeking the co-signatures of other lawmakers to the letter, which is available on the American College of Radiology website: https://www.acr.org/-/media/ACR/Files/Advocacy/ AIA/Suozzi-Wenstrup-SMB-Letter-102121.pdf ?Unfortunately, the parameters of the IDR process in the IFR released on September 30 do not reflect the way the law was written, do not reflect a policy that could have passed Congress, and do not create a balanced process to settle payment disputes. The IFR directs IDR entities to begin with the assumption that the median in-network rate is the appropriate payment amount prior to considering other factors. This directive establishes a de-facto benchmark rate, making the median in-network rate the default factor considered in the IDR process. This approach is contrary to statute and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and jeopardize patient access to care ? the exact opposite of the goal of the law. It could also have a broad impact on reimbursement for in-network services, which could exacerbate existing health disparities and patient access issues in rural and urban underserved communities.?
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PARA Weekly eJournal: November 17, 2021
NO SURPRISES PART II DISPUTED PAYMENT REGS CRITICIZED
The American College of Radiology, the American College of Emergency Physicians, and the American and other provider-led organizations have asked their members to encourage their representatives in Congress to sign the draft letter.Links to the articles on the association websites are provided below: https://www.acr.org/Advocacy-and-Economics/Advocacy-News/Advocacy-News-Issues/In-theOct-23-2021-Issue/Bipartisan-US-House-Members-Urge-Colleagues-to-Sign-Surprise-Billing-Letter
https://www.acep.org/home-page-redirects/latest-news/no-surprises-act-interim-final-rule-acep-response/
https://www.asahq.org/advocacy-and-asapac/fda-and-washington-alerts/washington-alerts/2021/ 10/asa-fighting-flawed-new-surprise-medical-bill-regulations
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PARA Weekly eJournal: November 17, 2021
2022 OPPS UPDATE: INPATIENT ONLY LIST ADDITIONS
In t h e 2022 OPPS Fin al Ru le, M edicar e added 293 codes t o OPPS Adden du m E, ?In pat ien t on ly ?, as com par ed w it h t h e sam e list f or 2021. Th ese HCPCS w ill n ot be r eim bu r sed on ou t pat ien t claim s in 2022, u n less t h e pat ien t expir ed bef or e adm ission t o in pat ien t st at u s or t r an sf er t o an ot h er f acilit y. CMS is restoring inpatient-only status to most of the codes that were dropped in 2021 from the inpatient-only list.Of particular note, CPT® 27132 (conversion of previous hip surgery to total hip arthroplasty) one of two CPT® codes reporting total hip arthroplasty, along with most of the partial and revision hip arthroplasty procedures, are back on the list in 2022. However, CPT® 27130 (total hip arthroplasty) is not on the inpatient-only list. Presumably, since CPT® 27130 was deleted from the inpatient-only list in 2020, it was not caught up with the restoration of other codes dropped in 2021.A list of the newly added codes is available on the PARA Data Editor Advisor tab; search ?2022? in the summary field, and select ?Addendum E ? Inpatient only 2022 OPPS Final Rule?.
A brief excerpt from the 2022 Addendum E file is provided here. The newly added HCPCS are identified with the letters ?CH? in the column labeled CI (Change Indicator):
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PARA Weekly eJournal: November 17, 2021
2022 OPPS UPDATE: INPATIENT ONLY LIST ADDITIONS
CMS summarized the changes in its Newsroom Fact Sheet on the CY2022 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule: https://www.cms.gov/newsroom/fact-sheets/cy-2022-medicare-hospital-outpatientprospective-payment-system-and-ambulatory-surgical-center-0 Changes to the Inpatient Only List
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PARA Weekly eJournal: November 17, 2021
2022 OPPS UPDATE: INPATIENT ONLY LIST ADDITIONS
CPT® 27130, which represents a new total hip arthroplasty procedure which is neither a conversion or revision of a previous procedure, will remain payable as an outpatient procedure as OPPS status J1, as displayed in the 2022 OPPS Addendum B:
There are two limited exceptions which permit a hospital to report an inpatient-only HCPCS on an outpatient claim.In April of 2015, CMS updated the ?Inpatient Only? policy in a transmittal describing the permissible circumstances: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3238CP.pdf
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PARA Weekly eJournal: November 17, 2021
2022 OPPS UPDATE: INPATIENT ONLY LIST ADDITIONS
A link and excerpts from the Medicare Claims Processing Manual, which repeats the instruction, is provided below: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf
M edicar e Claim s Pr ocessin g M an u al, Ch apt er 4 180.7 - In pat ien t -on ly Ser vices (Rev. 4513, Issued: 02-04-2020, Effective: 01-01- 2020, Implementation: 01-06-2020)
? There are two exceptions to the policy of not paying for outpatient services furnished on the same day with an ?inpatient-only? service that would be paid under the OPPS if the inpatient service had not been furnished: Except ion 1:
If the ?inpatient-only? service is defined in CPT® to be a ?separate procedure? and the other services billed with the ?inpatient-only? service contain a procedure that can be paid under the OPPS and that has an OPPS SI=T on the same date as the ?inpatient-only? procedure or OPPS SI = J1 on the same claim as the ?inpatient only? procedure, then the ?inpatient-only? service is denied but CMS makes payment for the separate procedure and any remaining payable OPPS services. The list of ?separate procedures? is available with the Integrated Outpatient Code Editor (I/OCE) documentation. See http://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/. Except ion 2: If an ?inpatient-only? service is furnished but the patient expires before inpatient admission or transfer to another hospital and the hospital reports the ?inpatient only? service with modifier ?CA?, then CMS makes a single payment for all services reported on the claim, including the ?inpatient only? procedure, through one unit of APC 5881, (Ancillary outpatient services when the patient dies.) Hospitals should report modifier CA on only one procedure. 16
PARA Weekly eJournal: November 17, 2021
PAMA REPORTING CLARIFIED FOR ACQUIRED LABORATORIES
During a Medicare Clinical Laboratory Fee Schedule (CLFS) Private Payer Data Collection and Reporting Policies webinar conducted on Wednesday, November 10, 2021, CMS addressed the responsibility for reporting?applicable information? for ?applicable laboratories? which changed ownership during or since the reporting period, January 1, 2019 through June 30, 2019. A screenshot from the slide deck follows:
We expect CMS to post a recording, transcript, and copy of the slide deck provided during the November 10, 2021 call, but that information has not been published as of this writing. Interested readers may also refer to the Additional Frequently Asked Questions document updated on April 20, 2021. https://www.cms.gov/files/document/frequently-asked-questions-cy-2021-clfs.pdf
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PARA Weekly eJournal: November 17, 2021
OIG WORKPLAN: AUDIT OF ED PROFESSIONAL E/M CHARGES
The HHS Office of the Inspector General will issue a report in 2022 examining whether Medicare payments to providers for emergency department professional E/M services were appropriate, medically necessary, and paid in accordance with Medicare requirements. A link and a summary of the audit objective is provided below: https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000612.asp
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PARA Weekly eJournal: November 17, 2021
NEW AND REVISED PLACE OF SERVICE CODES FOR TELEHEALTH
On October 13, 2021, Medicare published a Change Request (12427) with details of a new Place of Service (POS) code (10) for Telehealth and revised the description for the existing POS code (02) for Telehealth. The POS codes are to be reported on professional fee claims billed on the CMS1500/837p form.The new POS code descriptions will go into effect on January 1, 2022, with an implementation date of April 4, 2022. The addition of POS Code 10 lets payers know the telehealth services were provided in the patient?s home. The revision to POS Code 02 clarifies that the patient is located somewhere other than their home. r11045cp.pdf (cms.gov)
During the PHE, Medicare does not require the use of telehealth POS codes. MACs have been directed to instruct their providers to continue to bill according to current applicable rules. However, MACs are to adjudicate claims containing this new code should it appear on a claim the same way they would adjudicate claims with POS 02. 19
PARA Weekly eJournal: November 17, 2021
FDA TO WITHDRAW EUA ON COVID PCR TEST DECEMBER 31, 2021
On July 21, 2021, the CDC announced it will withdraw its Emergency Use Authorization (EUA) request for the CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel after December 31, 2021. The advanced notice allows laboratories to adopt and prepare to use an alternative FDA approved test. The 2019-Novel Coronavirus Real-Time RT-PCR Diagnostic Panel detects only COVID-19.The CDC suggests laboratories begin using a multiplex assay that can detect both COVID-19 and influenza, which will be save time and laboratory resources as we enter flu season. https://www.cdc.gov/csels/dls/locs/2021/07-21-2021-lab-alert-Changes_CDC_ RT-PCR_SARS-CoV-2_Testing_1.html
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PARA Weekly eJournal: November 17, 2021
COVID-19 UPDATE PARA Healt h Car e An alyt ics continues to update COVID-19 coding and billing information based on frequently changing guidelines and regulations from CMS and payers. All coding must be supported by medical documentation.
Download the updated Guidebook by clicking here. 21
Updat ed An d Revised Sept em ber 22, 2021
PARA Weekly eJournal: November 17, 2021
MLN CONNECTS
PARA invites you to check out the mlnconnects page available from the Centers For Medicare and Medicaid (CMS). It's chock full of news and information, training opportunities, events and more! Each week PARA will bring you the latest news and links to available resources. Click each link for the PDF!
Th u r sday, Novem ber 11, 2021 New s -
Provider Enrollment Application Fee for CY 2022 LTCH & IRF: CY 2022 QRP Updates Critical Care E/M Services: Comparative Billing Report in November Diabetes Resources for You & Your Patients
Com plian ce -
DMEPOS: Bill Correctly for Items Provided During Inpatient Stays
Claim s, Pr icer s, & Codes -
HCPCS Application Summaries & Coding Decisions: 510(k)-Cleared Wound Care Products
Even t s -
HCPCS Public Meeting ? December 1 & 2
M LN M at t er s® Ar t icles -
Medicare Part B CLFS: Revised Information for Laboratories on Collecting & Reporting Data for the Private Payor Rate-Based Payment System
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PARA Weekly eJournal: November 17, 2021
There were TWO new or revised MedLearns released this week. To go to the full Transmittal document simply click on the screen shot or the link.
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FIND ALL THESE MEDLEARNS IN THE ADVISOR TAB OF THE PDE
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PARA Weekly eJournal: November 17, 2021
The link to this MedLearn MM12403
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The link to this MedLearn MM12446
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PARA Weekly eJournal: November 17, 2021
There were SEVENTEEN new or revised Transmittals released this week. To go to the full Transmittal document simply click on the screen shot or the link.
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FIND ALL THESE TRANSMITTALS IN THE ADVISOR TAB OF THE PDE
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PARA Weekly eJournal: November 17, 2021
The link to this Transmittal R11127COM
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The link to this Transmittal R11116CP
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The link to this Transmittal R11114CP
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The link to this Transmittal R11115CP
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The link to this Transmittal R11113CP
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The link to this Transmittal R11117CP
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The link to this Transmittal R11123OTN
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The link to this Transmittal R11120BP
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The link to this Transmittal R11119CP
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The link to this Transmittal R11119NCD
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The link to this Transmittal R11118CP
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The link to this Transmittal R11104OTN
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The link to this Transmittal R11097FM
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The link to this Transmittal R11103OTN
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The link to this Transmittal R11102CP
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The link to this Transmittal R11098OTN
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The link to this Transmittal R11100OTN
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PARA Weekly eJournal: November 17, 2021
We're revving up for a bold new look and an even bolder set of services.
Coming Soon! 44