Billing/CPU Department P.O. Box 71, Wilkes Barre, PA Tel: (973) Fax: (973)

Transcription

1 5/17/2018 Billing/CPU Department P.O. Box 71, Wilkes Barre, PA Tel: (973) Fax: (973) SEDGWICK CMS Kristene Halversen PO BOX LEXINGTON, KY Re: Bill Repricing ADVANCE AUTO PARTS Dear Kristene Halversen, Pursuant to your request, enclosed please find the fee scheduled/repriced Personal Injury Protection bills. Please do not hesitate to contact us with any questions. Our telephone number is Thank you, we appreciate your business. Sincerely, Active Care PIP Billing Department - - Enclosures # of Copies 1

2 Repricing Invoice Carrier: ADVANCE AUTO PARTS PO BOX LEXINGTON, KY Acct Claim # : B Adjuster: Halversen, Kristene SSN: XXX-XX-X999 Claimant : Jerome, Jacqueline Case # : AAPP Date of Loss : 09/24/2016 Batch#/ Bill# : / 14 Pay Category : 0 Patient Acct # : Z43ZFK1 Provider Tax ID : Provider: Radiology Advantage New Jerse Weltman, David PO Box 2044 INDIANAPOLIS, IN DOS Period: 02/28/2018 Invoice# : Invoice Date : 05/17/2018 Verification Date: 05/11/2018 Invoice Amount Due: $4.01 Due Date: 06/16/2018 FEIN: Please include invoice # on your payment and Remit To: First MCO 2740 Route 10, Suite 304 MORRIS PLAINS, NJ JF11772 DOS Period Service Modifiers Units Provider Charge Fee Schedule / U&C Repriced Allowance Reduction Fee Expl 02/28/ $56.00 $56.00 $53.20 $ Explanation s: X-RAY EXAM CHEST 2 VIEWS $56.00 $56.00 $53.20 $2.80 $0.76 Total Line Charges: $1.25 Bill Header Charge: $2.00 Total Invoice: $ PRICING APPLIED VIA PRIME HEALTH SERVICES. FOR INQUIRIES, PLEASE CONTACT (866) /17/2018 8:30:28 AM Bill ID: Page 1 of 1

3 Explanation of Review (E.O.R.) Provider Radiology Advantage New Jerse Weltman, David PO Box 2044 INDIANAPOLIS, IN Acct Claim # : B SSN : XXX-XX-X999 Claimant : Jerome, Jacqueline Case # : AAPP Date of Loss : 09/24/2016 Batch #/Bill # : / 14 Provider Tax ID : EOR Invoice# : EOR Date : 05/17/2018 Verification Date: 05/11/2018 Patient Acct # : Z43ZFK1 File : 401 Pay Category : 0 Carrier: ADVANCE AUTO PARTS PO BOX Copay: LEXINGTON, KY Deductible: Amount Due: Adjuster: Halversen, Kristene DOS Period: 02/28/2018 JF11772 DOS Period Service Modifiers Units Provider Charge Fee Schedule / U&C Repriced Allowance Expl 02/28/ $56.00 $56.00 $ Explanation s: X-RAY EXAM CHEST 2 VIEWS Totals: $56.00 $56.00 $ PRICING APPLIED VIA PRIME HEALTH SERVICES. FOR INQUIRIES, PLEASE CONTACT (866) Unless otherwise noted, charges were reduced for exceeding the guidelines of medical fees of the state of New York. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation. If you have any questions, please call First Managed Care Option at (973) or send to CustomerService@FirstMCO.com. 05/17/2018 8:30:29 AM P.O. BOX 71, WILKES BARRE, PA CPT only (c) American Medical Association. All rights reserved. CDT-4 and CDT-2013 Current Dental Terminology is copyright American Dental Association. All rights reserved. Relative Value American Society of Anesthesiologists. All rights reserved. Page 1 of 1

4 Received by First MCO Friday May 11, :34 PM

5 Repricing Invoice Carrier: ADVANCE AUTO PARTS PO BOX LEXINGTON, KY Acct Claim # : B Adjuster: Halversen, Kristene SSN: XXX-XX-X999 Claimant : Jerome, Jacqueline Case # : AAPP Date of Loss : 09/24/2016 Batch#/ Bill# : / 15 Pay Category : 0 Patient Acct # : Provider Tax ID : Provider: Brookhaven Memorial Hospital PO Box 350 PLAINVIEW, NY DOS Period: 02/28/2018 Invoice# : Invoice Date : 05/17/2018 Verification Date: 05/11/2018 Invoice Amount Due: $17.00 Due Date: 06/16/2018 FEIN: Please include invoice # on your payment and Remit To: First MCO 2740 Route 10, Suite 304 MORRIS PLAINS, NJ JF11772 DOS Period Rev Service Modifiers Units Provider Charge Fee Schedule / U&C Repriced Allowance Reduction Fee Expl 02/28/ $ $ $ $0.00 EMERGENCY ROOM / EMERGENCY DEPT VISIT 02/28/ TC 1 $46.97 $46.97 $46.97 $0.00 RADIOLOGY-DIAGNOSTIC / Expired CPT 02/28/ $21.26 $21.26 $21.26 $0.00 LABORATORY / COMPREHEN METABOLIC PANEL 02/28/ $6.59 $6.59 $6.59 $0.00 LABORATORY / URINALYSIS AUTO W/O SCOPE 02/28/ $9.53 $0.00 $0.00 $ LABORATORY / ASSAY GLUCOSE BLOOD QUANT 02/28/ $15.35 $15.35 $15.35 $0.00 LABORATORY PATHOLOGICAL / ASSAY OF TROPONIN QUANT 02/28/ $16.86 $16.86 $16.86 $0.00 LABORATORY / CHORIONIC GONADOTROPIN ASSAY 02/28/ $13.57 $13.57 $13.57 $0.00 LABORATORY / COMPLETE CBC W/AUTO DIFF WBC 02/28/ $9.16 $4.58 $4.58 $ LABORATORY / ROUTINE VENIPUNCTURE 05/17/2018 8:44:23 AM Bill ID: Page 1 of 2

6 EOR/Invoice #: ; Case#: AAPP ; Claimant: Jerome, Jacqueline; Provider: Brookhaven Memorial Hospital DOS Period Rev Service Modifiers Units Provider Charge Fee Schedule / U&C Repriced Allowance Reduction Fee Repricing Invoice continued... JF11772 Expl 02/28/ $9.16 $9.16 $9.16 $0.00 LABORATORY / CAPILLARY BLOOD DRAW 02/28/ $41.41 $41.41 $41.41 $0.00 PROFESSIONAL FEES (SEE ALSO 97X AND 98X) / ELECTROCARDIOGRAM TRACING 02/28/ $10.88 $0.00 $0.00 $0.00 FN3 Explanation s: PHARMACY (ALSO SEE 063X, AN EXTENSION OF 025X) / $ $ $ $0.00 $0.00 Total Line Charges: $15.00 Bill Header Charge: $2.00 Total Invoice: $ ALLOWANCE WAS CALCULATED AT 50% OF THE GLOBAL SURGERY FEE AS PER THE MULTIPLE/BILATERAL SURGERY RULES. 200 PER CCI EDITS, THE VALUE OF THIS PROCEDURE IS INCLUDED IN THE VALUE OF THE COMPREHENSIVE PROCEDURE. FN3 NO ALLOWANCE HAS BEEN RECOMMENDED AS THIS CODE IS CONSIDERED AS A BUNDLED AND/OR PACKAGED SERVICE OR PROCEDURE BY THE STATE. 05/17/2018 8:44:23 AM Bill ID: Page 2 of 2

7 Explanation of Review (E.O.R.) Provider Brookhaven Memorial Hospital PO Box 350 PLAINVIEW, NY Acct Claim # : B SSN : XXX-XX-X999 Claimant : Jerome, Jacqueline Case # : AAPP Date of Loss : 09/24/2016 Batch #/Bill # : / 15 Provider Tax ID : EOR Invoice# : EOR Date : 05/17/2018 Verification Date: 05/11/2018 Patient Acct # : File : 1700 Pay Category : 0 Carrier: ADVANCE AUTO PARTS PO BOX Copay: LEXINGTON, KY Deductible: Amount Due: Adjuster: Halversen, Kristene DOS Period: 02/28/2018 JF11772 DOS Period Rev Service Modifiers Units Provider Charge Fee Schedule / U&C Repriced Allowance Expl 02/28/ $ $ $ EMERGENCY ROOM / EMERGENCY DEPT VISIT 02/28/ TC 1 $46.97 $46.97 $46.97 RADIOLOGY-DIAGNOSTIC / Expired CPT 02/28/ $21.26 $21.26 $21.26 LABORATORY / COMPREHEN METABOLIC PANEL 02/28/ $6.59 $6.59 $6.59 LABORATORY / URINALYSIS AUTO W/O SCOPE 02/28/ $9.53 $0.00 $ LABORATORY / ASSAY GLUCOSE BLOOD QUANT 02/28/ $15.35 $15.35 $15.35 LABORATORY PATHOLOGICAL / ASSAY OF TROPONIN QUANT 02/28/ $16.86 $16.86 $16.86 LABORATORY / CHORIONIC GONADOTROPIN ASSAY 02/28/ $13.57 $13.57 $13.57 LABORATORY / COMPLETE CBC W/AUTO DIFF WBC 02/28/ $9.16 $4.58 $ LABORATORY / ROUTINE VENIPUNCTURE 02/28/ $9.16 $9.16 $9.16 LABORATORY / CAPILLARY BLOOD DRAW 02/28/ $41.41 $41.41 $41.41 PROFESSIONAL FEES (SEE ALSO 97X AND 98X) / ELECTROCARDIOGRAM TRACING 02/28/ $10.88 $0.00 $0.00 FN3 PHARMACY (ALSO SEE 063X, AN EXTENSION OF 025X) / Unless otherwise noted, charges were reduced for exceeding the guidelines of medical fees of the state of New York. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation. If you have any questions, please call First Managed Care Option at (973) or send to CustomerService@FirstMCO.com. 05/17/2018 8:44:24 AM P.O. BOX 71, WILKES BARRE, PA CPT only (c) American Medical Association. All rights reserved. CDT-4 and CDT-2013 Current Dental Terminology is copyright American Dental Association. All rights reserved. Relative Value American Society of Anesthesiologists. All rights reserved. Page 1 of 2

8 Explanation of Review (E.O.R.) continued... EOR/Invoice #: ; Case#: AAPP ; Claimant: Jerome, Jacqueline; Provider: Brookhaven Memorial Hospital DOS Period Rev Explanation s: Service Modifiers Units Provider Charge Fee Schedule / U&C Repriced Allowance Totals: $ $ $ JF11772 Expl 018 ALLOWANCE WAS CALCULATED AT 50% OF THE GLOBAL SURGERY FEE AS PER THE MULTIPLE/BILATERAL SURGERY RULES. 200 PER CCI EDITS, THE VALUE OF THIS PROCEDURE IS INCLUDED IN THE VALUE OF THE COMPREHENSIVE PROCEDURE. FN3 NO ALLOWANCE HAS BEEN RECOMMENDED AS THIS CODE IS CONSIDERED AS A BUNDLED AND/OR PACKAGED SERVICE OR PROCEDURE BY THE STATE. Unless otherwise noted, charges were reduced for exceeding the guidelines of medical fees of the state of New York. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation. If you have any questions, please call First Managed Care Option at (973) or send to CustomerService@FirstMCO.com. 05/17/2018 8:44:24 AM P.O. BOX 71, WILKES BARRE, PA CPT only (c) American Medical Association. All rights reserved. CDT-4 and CDT-2013 Current Dental Terminology is copyright American Dental Association. All rights reserved. Relative Value American Society of Anesthesiologists. All rights reserved. Page 2 of 2

9 Received by First MCO Friday May 11, :34 PM

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29 Repricing Invoice Carrier: ADVANCE AUTO PARTS PO BOX LEXINGTON, KY Acct Claim # : B Adjuster: Halversen, Kristene SSN: XXX-XX-X999 Claimant : Jerome, Jacqueline Case # : AAPP Date of Loss : 09/24/2016 Batch#/ Bill# : / 1 Pay Category : 0 Patient Acct # : Provider Tax ID : Provider: South Shore Neurologic Assoc, Mebrahtu, Samson 712 Main St ISLIP, NY DOS Period: 03/05/2018 Invoice# : Invoice Date : 05/17/2018 Verification Date: 05/11/2018 Invoice Amount Due: $39.93 Due Date: 06/16/2018 FEIN: Please include invoice # on your payment and Remit To: First MCO 2740 Route 10, Suite 304 MORRIS PLAINS, NJ JF11772 DOS Period Service Modifiers Units Provider Charge Fee Schedule / U&C Repriced Allowance Reduction Fee Expl 03/05/ $34.30 $34.30 $22.50 $ RHYTHM ECG WITH REPORT 03/05/ $ $ $ $ Explanation s: EEG AWAKE AND ASLEEP $ $ $ $ $35.43 Total Line Charges: $2.50 Bill Header Charge: $2.00 Total Invoice: $ PRICING APPLIED VIA PRIME HEALTH SERVICES. FOR INQUIRIES, PLEASE CONTACT (866) /17/2018 8:47:41 AM Bill ID: Page 1 of 1

30 Explanation of Review (E.O.R.) Provider South Shore Neurologic Assoc, Mebrahtu, Samson 712 Main St ISLIP, NY Acct Claim # : B SSN : XXX-XX-X999 Claimant : Jerome, Jacqueline Case # : AAPP Date of Loss : 09/24/2016 Batch #/Bill # : / 1 Provider Tax ID : EOR Invoice# : EOR Date : 05/17/2018 Verification Date: 05/11/2018 Patient Acct # : File : 3993 Pay Category : 0 Carrier: ADVANCE AUTO PARTS PO BOX Copay: LEXINGTON, KY Deductible: Amount Due: Adjuster: Halversen, Kristene DOS Period: 03/05/2018 JF11772 DOS Period Service Modifiers Units Provider Charge Fee Schedule / U&C Repriced Allowance Expl 03/05/ $34.30 $34.30 $ RHYTHM ECG WITH REPORT 03/05/ $ $ $ Explanation s: EEG AWAKE AND ASLEEP Totals: $ $ $ PRICING APPLIED VIA PRIME HEALTH SERVICES. FOR INQUIRIES, PLEASE CONTACT (866) Unless otherwise noted, charges were reduced for exceeding the guidelines of medical fees of the state of New York. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation. If you have any questions, please call First Managed Care Option at (973) or send to CustomerService@FirstMCO.com. 05/17/2018 8:47:42 AM P.O. BOX 71, WILKES BARRE, PA CPT only (c) American Medical Association. All rights reserved. CDT-4 and CDT-2013 Current Dental Terminology is copyright American Dental Association. All rights reserved. Relative Value American Society of Anesthesiologists. All rights reserved. Page 1 of 1

31 Received by First MCO Friday May 11, :34 PM

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33 Repricing Invoice Carrier: ADVANCE AUTO PARTS PO BOX LEXINGTON, KY Acct Claim # : B Adjuster: Halversen, Kristene SSN: XXX-XX-X999 Claimant : Jerome, Jacqueline Case # : AAPP Date of Loss : 09/24/2016 Batch#/ Bill# : / 3 Pay Category : 0 Patient Acct # : Provider Tax ID : Provider: South Shore Neurologic Assoc, Firouztale, Edward 712 Main St ISLIP, NY DOS Period: 03/06/2018 Invoice# : Invoice Date : 05/17/2018 Verification Date: 05/11/2018 Invoice Amount Due: $19.64 Due Date: 06/16/2018 FEIN: Please include invoice # on your payment and Remit To: First MCO 2740 Route 10, Suite 304 MORRIS PLAINS, NJ JF11772 DOS Period Service Modifiers Units Provider Charge Fee Schedule / U&C Repriced Allowance Reduction Fee Expl 03/06/ $ $ $88.00 $ Explanation s: OFFICE/OUTPATIENT VISIT EST $ $ $88.00 $60.69 $16.39 Total Line Charges: $1.25 Bill Header Charge: $2.00 Total Invoice: $ PRICING APPLIED VIA PRIME HEALTH SERVICES. FOR INQUIRIES, PLEASE CONTACT (866) /17/2018 9:01:06 AM Bill ID: Page 1 of 1

34 Explanation of Review (E.O.R.) Provider South Shore Neurologic Assoc, Firouztale, Edward 712 Main St ISLIP, NY Acct Claim # : B SSN : XXX-XX-X999 Claimant : Jerome, Jacqueline Case # : AAPP Date of Loss : 09/24/2016 Batch #/Bill # : / 3 Provider Tax ID : EOR Invoice# : EOR Date : 05/17/2018 Verification Date: 05/11/2018 Patient Acct # : File : 1964 Pay Category : 0 Carrier: ADVANCE AUTO PARTS PO BOX Copay: LEXINGTON, KY Deductible: Amount Due: Adjuster: Halversen, Kristene DOS Period: 03/06/2018 JF11772 DOS Period Service Modifiers Units Provider Charge Fee Schedule / U&C Repriced Allowance Expl 03/06/ $ $ $ Explanation s: OFFICE/OUTPATIENT VISIT EST Totals: $ $ $ PRICING APPLIED VIA PRIME HEALTH SERVICES. FOR INQUIRIES, PLEASE CONTACT (866) Unless otherwise noted, charges were reduced for exceeding the guidelines of medical fees of the state of New York. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation. If you have any questions, please call First Managed Care Option at (973) or send to CustomerService@FirstMCO.com. 05/17/2018 9:01:06 AM P.O. BOX 71, WILKES BARRE, PA CPT only (c) American Medical Association. All rights reserved. CDT-4 and CDT-2013 Current Dental Terminology is copyright American Dental Association. All rights reserved. Relative Value American Society of Anesthesiologists. All rights reserved. Page 1 of 1

35 Received by First MCO Friday May 11, :34 PM

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41 Repricing Invoice Carrier: ADVANCE AUTO PARTS PO BOX LEXINGTON, KY Acct Claim # : B Adjuster: Halversen, Kristene SSN: XXX-XX-X999 Claimant : Jerome, Jacqueline Case # : AAPP Date of Loss : 09/24/2016 Batch#/ Bill# : / 4 Pay Category : 0 Patient Acct # : / Provider Tax ID : Provider: LONG ISLAND ENT ASSOCIATES PC Youngerman, Jay S Suite Old Country Road PLAINVIEW, NY DOS Period: 04/16/2018 Invoice# : Invoice Date : 05/17/2018 Verification Date: 05/11/2018 Invoice Amount Due: $33.64 Due Date: 06/16/2018 FEIN: Please include invoice # on your payment and Remit To: First MCO 2740 Route 10, Suite 304 MORRIS PLAINS, NJ JF11803 DOS Period Service Modifiers Units Provider Charge Fee Schedule / U&C Repriced Allowance Reduction Fee Expl 04/16/ $92.97 $92.97 $65.08 $ OFFICE/OUTPATIENT VISIT EST 04/16/ $72.84 $72.84 $50.99 $ COMPREHENSIVE HEARING TEST 04/16/ $72.84 $72.84 $50.99 $ EVOKED AUDITORY TST COMPLETE 04/16/ $47.15 $47.15 $47.15 $0.00 ACOUSTIC IMMITANCE TESTING 04/16/ $31.43 $31.43 $9.00 $ Explanation s: TONE DECAY HEARING TEST $ $ $ $94.02 $25.39 Total Line Charges: $6.25 Bill Header Charge: $2.00 Total Invoice: $ PRICING APPLIED VIA PRIME HEALTH SERVICES. FOR INQUIRIES, PLEASE CONTACT (866) /17/2018 9:04:47 AM Bill ID: Page 1 of 1

42 Explanation of Review (E.O.R.) Provider LONG ISLAND ENT ASSOCIATES PC Youngerman, Jay S Suite Old Country Road PLAINVIEW, NY Acct Claim # : B SSN : XXX-XX-X999 Claimant : Jerome, Jacqueline Case # : AAPP Date of Loss : 09/24/2016 Batch #/Bill # : / 4 Provider Tax ID : EOR Invoice# : EOR Date : 05/17/2018 Verification Date: 05/11/2018 Patient Acct # : / File : 3364 Pay Category : 0 Carrier: ADVANCE AUTO PARTS PO BOX Copay: LEXINGTON, KY Deductible: Amount Due: Adjuster: Halversen, Kristene DOS Period: 04/16/2018 JF11803 DOS Period Service Modifiers Units Provider Charge Fee Schedule / U&C Repriced Allowance Expl 04/16/ $92.97 $92.97 $ OFFICE/OUTPATIENT VISIT EST 04/16/ $72.84 $72.84 $ COMPREHENSIVE HEARING TEST 04/16/ $72.84 $72.84 $ EVOKED AUDITORY TST COMPLETE 04/16/ $47.15 $47.15 $47.15 ACOUSTIC IMMITANCE TESTING 04/16/ $31.43 $31.43 $ Explanation s: TONE DECAY HEARING TEST Totals: $ $ $ PRICING APPLIED VIA PRIME HEALTH SERVICES. FOR INQUIRIES, PLEASE CONTACT (866) Unless otherwise noted, charges were reduced for exceeding the guidelines of medical fees of the state of New York. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation. If you have any questions, please call First Managed Care Option at (973) or send to CustomerService@FirstMCO.com. 05/17/2018 9:04:48 AM P.O. BOX 71, WILKES BARRE, PA CPT only (c) American Medical Association. All rights reserved. CDT-4 and CDT-2013 Current Dental Terminology is copyright American Dental Association. All rights reserved. Relative Value American Society of Anesthesiologists. All rights reserved. Page 1 of 1

43 Received by First MCO Friday May 11, :34 PM

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47 Repricing Invoice Carrier: ADVANCE AUTO PARTS PO BOX LEXINGTON, KY Acct Claim # : B Adjuster: Halversen, Kristene SSN: XXX-XX-X999 Claimant : Jerome, Jacqueline Case # : AAPP Date of Loss : 09/24/2016 Batch#/ Bill# : / 5 Pay Category : 0 Patient Acct # : Provider Tax ID : Provider: Eye Vision Associates Meltzer, Bradley R 271 Smithtown Blvd. NESCONSET, NY DOS Period: 04/19/2018 Invoice# : Invoice Date : 05/17/2018 Verification Date: 05/11/2018 Invoice Amount Due: $3.25 Due Date: 06/16/2018 FEIN: Please include invoice # on your payment and Remit To: First MCO 2740 Route 10, Suite 304 MORRIS PLAINS, NJ JF11767 DOS Period Service Modifiers Units Provider Charge Fee Schedule / U&C Repriced Allowance Reduction Fee Expl 04/19/ $ $55.69 $55.69 $0.00 EYE EXAM ESTABLISH PATIENT $ $55.69 $55.69 $0.00 $0.00 Total Line Charges: $1.25 Bill Header Charge: $2.00 Total Invoice: $ /17/2018 9:07:17 AM Bill ID: Page 1 of 1

48 Explanation of Review (E.O.R.) Provider Eye Vision Associates Meltzer, Bradley R 271 Smithtown Blvd. NESCONSET, NY Acct Claim # : B SSN : XXX-XX-X999 Claimant : Jerome, Jacqueline Case # : AAPP Date of Loss : 09/24/2016 Batch #/Bill # : / 5 Provider Tax ID : EOR Invoice# : EOR Date : 05/17/2018 Verification Date: 05/11/2018 Patient Acct # : File : 325 Pay Category : 0 Carrier: ADVANCE AUTO PARTS PO BOX Copay: LEXINGTON, KY Deductible: Amount Due: Adjuster: Halversen, Kristene DOS Period: 04/19/2018 JF11767 DOS Period Service Modifiers Units Provider Charge Fee Schedule / U&C Repriced Allowance Expl 04/19/ $ $55.69 $55.69 EYE EXAM ESTABLISH PATIENT Totals: $ $55.69 $55.69 Unless otherwise noted, charges were reduced for exceeding the guidelines of medical fees of the state of New York. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation. If you have any questions, please call First Managed Care Option at (973) or send to CustomerService@FirstMCO.com. 05/17/2018 9:07:17 AM P.O. BOX 71, WILKES BARRE, PA CPT only (c) American Medical Association. All rights reserved. CDT-4 and CDT-2013 Current Dental Terminology is copyright American Dental Association. All rights reserved. Relative Value American Society of Anesthesiologists. All rights reserved. Page 1 of 1

49 Received by First MCO Friday May 11, :34 PM

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