The enclosed WCB Form(s) (C8.1b) and/or (C8.4) have been filed with the NYS WCB for adjudication. By law, the Carrier is required to send you a copy.

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1 James Keating P.O. BOX 34 REMSENBURG, NY The enclosed WCB Form(s) (C8.1b) and/or (C8.4) have been filed with the NYS WCB for adjudication. By law, the Carrier is required to send you a copy. You are NOT responsible for any disputed amounts. Please note: Treatment is NOT being denied. The Carrier's objection to payment is based on the provider not following the WCB MTG recommendations.

2 PLEASE SCAN ALL PAGES OF THIS ATTACHMENT TOGETHER: C8.1, BILL AND CID NOTICE OF TREATMENT ISSUE(S)/DISPUTED BILL ISSUE(S) CHECK TYPE OF CASE: WORKERS' COMPENSATION VOLUNTEER FIREFIGHTER VOLUNTEER AMBULANCE WORKER ANSWER ALL QUESTIONS FULLY ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 1. W.C.B Case Number 2. Carrier Case Number C Carrier Code 4. Date of Injury 5. Social Security Number 6. Claimant Name Address to which notices should be sent Apt. No. 7. Employer 8. Carrier 9. Claimant's Doctor *In volunteer firefighters' and volunteer ambulance workers' benefit cases, the liable political subdivision (or unaffiliated ambulance service as defined in Sec. 30 VAWBL) is deemed to be the "EMPLOYER." PART A PART B NOTICE OF OBJECTION NOTICE OF OBJECTION TO PAYMENT OF A BILL REGARDING FURTHER OR FUTURE TREATMENT FOR TREATMENT PROVIDED (Notice must be filed within 5 days of denial/termination/withdrawal) (Notice must be properly completed and filed within 45 days of submission of bill. Failure to pay undisputed portion of bill may subject carrier to interest on The carrier: that portion). Denies authorization of, costing more than $1,000 or requiring authorization under the Medical Treatment Guidelines, requested by Dr. on based upon the conflicting medical report* of Dr. dated. Withdraws authorization for granted on to Dr. based upon conflicting medical report* of Dr.. Terminates further medical treatment after base upon conflicting medical report* of Dr. dated. Objects to further treatment because failed to attend a scheduled IME examination on. Denies authorization of as the medical appliance or program is not covered under the WCL. Raises the Medical Necessity of the special medical service of costing more than $1,000 requested by Dr. on based upon conflicting medical report* of Dr. dated in that the claim was controverted by Form C-7 dated and compensability has not been established. Requested treatment is not for an established site or condition. Explain Reason(s): Bill pertains to treatment: in New York State out of New York State dental Date of C-4/Bill WCB Document ID# of C-4/Bill (Note: If C-4/Bill is not in the Board's file, it must be submitted with this form.) Date of Treatment Amont of Bill $ Amount in Dispute $ The carrier raises the following legal objections to the above cited bill for treatment rendered: Claim has been controverted by Form C-7 dated liability has not been resolved. Prior authorization was not granted for treatment over $1,000. Request for treatment has been denied, withdrawn, or refused. Treatment Provided was not causally related to the compensable injury. Treatment provided within 30 days of initial treatment was outside of preferred provider organization (PPO). Medical Report for treatment was not timely filed or is legally defective. Medical appliance or program is not covered under the WCL. Provider is not authorized under the Workers' Compensation Law. Bill is not for treatment but for an evidentiary opinion. Amount of bill for dental treatment or treatment outside of NYS exceeds community standard. Diagnostic test was performed outside of network. Other (Specify): Compliance with Medical Treatment Guidelines: (ONLY applies to Knee, Shoulder, Neck and Mid and Low Back) Treatment provided was not based on correct application of the Guidelines. Treatment deviates from the Guidelines without securing a Variance. Treatment not consistent with the approved Variance. Variance denied without claimant timely requesting review or variance denied by Board Decision filed: Explain Reason(s)/MTG Reference: and *Conflicting Medical Opinion: The medical report constituting the conflicting medical opinion required for Part A must be filed simultaneously. If the report has been previously filed with the Board, identify the WCB Document ID No.: and date received by the Board: Note: Raising the issue of liability under WCL Sec. 25-a is not a valid reason for terminating medical treatment, denying authorization for a special service, or denying payment of a bill for treatment. WCL Sec. 13(a) states that "the providing of medical treatment and care...shall not constitute the payment of compensation under section 25-a of this chapter." Carrier is to pay for all causally related medical treatment and file for appropriate relief with Special Funds, if applicable. IT IS HEREWITH CERTIFIED THAT A COPY OF THIS FORM WAS SENT THIS DATE TO THE HEALTH PROVIDER. Dated: Tel No. & Ext.: Prepared By: Official Title: C (1-11) Prescribed by Chair Workers' Compensation Board State of New York REVERSE SIDE THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. SEE REVERSE SIDE

3 Keating, James; DoA: 02/25/2015; WCB: G Suffolk County Risk Management PO Box 6100 Hauppauge, NY CMC All Star Physical Therapy Peter Fiscina, PT 16 Memorial Blvd. East Moriches, NY Date of Letter: 08/31/2016 Date of Invoice: 08/10/2016 Date Invoice Rec'd: 08/22/2016 Provider Federal TIN: Point of Service: Regarding Patient Name: Keating, James CC#: 15W00292 Date of Injury: 02/25/2015 WCB#: G Code Description S43.402D Unspecified sprain of left shoulder joint, subs encntr S63.502D Unspecified sprain of left wrist, subsequent encounter D/O/S CPT Bill Unit Billed CPT Allow Unit Allowed Prv. Paid Obj/Note 03/02/ $ $14.96 $0.00 MC 03/02/ $ $12.22 $0.00 MC 03/02/ $ $17.82 $ d, MC 03/02/ $ $0.00 $ d 03/04/ $ $0.00 $0.00 1e, 13, C /04/ $ $0.00 $0.00 1e, 13, C /04/ $ $0.00 $0.00 1e, 13, C /04/ $ $0.00 $0.00 1e, 13, C /07/ $ $14.96 $0.00 MC 03/07/ $ $12.22 $0.00 MC 03/07/ $ $17.82 $ d, MC 03/07/ $ $0.00 $ d 03/09/ $ $0.00 $0.00 1e, 13, 03/09/ $ $0.00 $0.00 1e, 13, 03/09/ $ $0.00 $0.00 1e, 13, Claim Id: CE: Jessica Caruso Page 1

4 Keating, James; DoA: 02/25/2015; WCB: G Suffolk County Risk Management PO Box 6100 Hauppauge, NY D/O/S CPT Bill Unit Billed CPT Allow Unit Allowed Prv. Paid Obj/Note 03/09/ $ $0.00 $0.00 1e, 13, 03/16/ $ $0.00 $0.00 1e, 13, 03/16/ $ $0.00 $0.00 1e, 13, 03/16/ $ $0.00 $0.00 1e, 13, 03/16/ $ $0.00 $0.00 1e, 13, 03/21/ $ $0.00 $0.00 1e, 13, 03/21/ $ $0.00 $0.00 1e, 13, 03/21/ $ $0.00 $0.00 1e, 13, 03/21/ $ $0.00 $0.00 1e, 13, 03/23/ $ $0.00 $0.00 1e, 13, 03/23/ $ $0.00 $0.00 1e, 13, 03/23/ $ $0.00 $0.00 1e, 13, 03/23/ $ $0.00 $0.00 1e, 13, 03/25/ $ $0.00 $0.00 1e, 13, 03/25/ $ $0.00 $0.00 1e, 13, 03/25/ $ $0.00 $0.00 1e, 13, 03/25/ $ $0.00 $0.00 1e, 13, CMC Claim Id: CE: Jessica Caruso Page 2

5 Keating, James; DoA: 02/25/2015; WCB: G Suffolk County Risk Management PO Box 6100 Hauppauge, NY D/O/S CPT Bill Unit Billed CPT Allow Unit Allowed Prv. Paid Obj/Note 03/28/ $ $0.00 $0.00 1e, 13, 03/28/ $ $0.00 $0.00 1e, 13, 03/28/ $ $0.00 $0.00 1e, 13, 03/28/ $ $0.00 $0.00 1e, 13, 03/30/ $ $0.00 $0.00 1e, 13, 03/30/ $ $0.00 $0.00 1e, 13, 03/30/ $ $0.00 $0.00 1e, 13, 03/30/ $ $0.00 $0.00 1e, 13, Obj/Note Description 12d Maximum daily allowance applies PM & R Ground Rule # 11 and Chiro PM Ground Rule # 3 ( ). 13 Please see note in comment box below: 1e Treatment Authorization was: exceeded, denied OR never requested by Provider prior to rendering treatment. C8.113 Treatment was not based on correct application of Medical Treatment Guidelines. C8.1 will be filed or has been previously filed for this issue. PAYMENT DENIED. Treatment deviates from the Guidelines without securing a Variance. C8.1 will be filed or has been previously filed for this issue. PAYMENT DENIED. C8.115 Treatment not consistent with the approved Variance. C8.1 will be filed or has been previously filed for this issue. PAYMENT DENIED. C8.1 Filed: Variance denied without claimant timely requesting review, OR Variance denied by Board decision. Payment Denied. MC The fee for this line has been discounted per the contracted rates with MagnaCare PPO. Questions regarding the discounted rates should be directed to YOU MUST USE OPTION 3 to reach the proper department. Comments: 1) The variance granted was for physical therapy 2x a week for 4 weeks to the left shoulder. Date of service 3/4/16 represents the third visit in a weeks time. Treatment rendered was not to the variance. Therefore, payment is denied for this date. 2) Dates of service 3/9/16-3/23/16 are denied due to a variance not being secured. 3) Dates of service 3/24/16-3/30/16 are denied per Rescission Of The Order Of Chair filed 4/19/16 which stated, "The variance requested in the MG2 filed on 3/24/16 is denied." CMC Claim Id: CE: Jessica Caruso Page 3

6 Keating, James; DoA: 02/25/2015; WCB: G Suffolk County Risk Management PO Box 6100 Hauppauge, NY CMC Claim Examiner Comments: Balance Billed: $1, Balance Allowed: $90.00 Previously Paid: $0.00 Balance in Dispute: $1, A check will be sent under separate cover for the "Amount Allowed". All fees paid according to the NYS WCB fee schedule. Claims Examiner: Jessica Caruso Tel: Date: 08/31/2016 Claim Id: CE: Jessica Caruso Page 4

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