the enclosed wcb form(s) (c8.1b) and/or (c8.4) have been ... · c8.1 will be filed or has been...

James KeatingP.O. BOX 34REMSENBURG, NY 11960

The enclosed WCB Form(s) (C8.1b) and/or (C8.4) have been filed with the NYS WCB foradjudication. 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 onthe provider not following the WCB MTG recommendations.

NOTICE OF TREATMENT ISSUE(S)/DISPUTED BILL ISSUE(S)CHECK TYPE OF CASE: WORKERS' COMPENSATION VOLUNTEER FIREFIGHTER VOLUNTEER AMBULANCE WORKER

ANSWER ALL QUESTIONS FULLYALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS

3. Carrier Code 4. Date of Injury 5. Social Security Number1. W.C.B Case Number 2. Carrier Case Number

Name Address to which notices should be sent Apt. No.

6. Claimant

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 ANOTICE OF OBJECTION

REGARDING FURTHER OR FUTURE TREATMENT(Notice must be filed within 5 days of denial/termination/withdrawal)

The carrier:

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 requestedby 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):

PART BNOTICE OF OBJECTION TO PAYMENT OF A BILL

FOR TREATMENT PROVIDED(Notice must be properly completed and filed within 45 days of submission ofbill. Failure to pay undisputed portion of bill may subject carrier to interest onthat portion).

Bill pertains to treatment: in New York State out of New York State dentalDate 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 andliability 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:

*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: Prepared By:

Tel No. & Ext.: Official Title:

C-8.1

C-8.1.0 (1-11)Prescribed by ChairWorkers' Compensation BoardState of New York

REVERSE SIDE THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVESPEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. SEE REVERSE SIDE

PLEASE SCAN ALL PAGES OF THIS ATTACHMENT TOGETHER: C8.1, BILL AND CID 192709

Suffolk County Risk ManagementPO Box 6100

Hauppauge, NY 11788

All Star Physical TherapyPeter Fiscina, PT16 Memorial Blvd.

East Moriches, NY 11940

Date of Letter: 08/31/2016Date of Invoice: 08/10/2016Date Invoice Rec'd: 08/22/2016Provider Federal TIN: 010885087Point of Service: 11940

Regarding - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Patient Name: Keating, JamesDate of Injury: 02/25/2015

CC#: 15W00292WCB#: G1078858

Code DescriptionS43.402D 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

03/02/2016 97014 1 $20.48 97014 1 $14.96 $0.00 MC

03/02/2016 97035 1 $15.40 97035 1 $12.22 $0.00 MC

03/02/2016 97110 2 $61.14 97110 2 $17.82 $0.00 12d, MC

03/02/2016 97140 2 $65.14 97140 2 $0.00 $0.00 12d

03/04/2016 97014 1 $20.48 0 0 $0.00 $0.00 1e, 13,C8.115

03/04/2016 97035 1 $15.40 0 0 $0.00 $0.00 1e, 13,C8.115

03/04/2016 97110 2 $61.14 0 0 $0.00 $0.00 1e, 13,C8.115

03/04/2016 97140 2 $65.14 0 0 $0.00 $0.00 1e, 13,C8.115

03/07/2016 97014 1 $20.48 97014 1 $14.96 $0.00 MC

03/07/2016 97035 1 $15.40 97035 1 $12.22 $0.00 MC

03/07/2016 97110 2 $61.14 97110 2 $17.82 $0.00 12d, MC

03/07/2016 97140 2 $65.14 97140 2 $0.00 $0.00 12d

03/09/2016 97014 1 $20.48 0 0 $0.00 $0.00 1e, 13,C8.113,C8.114

03/09/2016 97035 1 $15.40 0 0 $0.00 $0.00 1e, 13,C8.113,C8.114

03/09/2016 97110 2 $61.14 0 0 $0.00 $0.00 1e, 13,C8.113,C8.114

Claim Id: 192709 CE: Jessica CarusoPage 1

CMC

Keating, James; DoA: 02/25/2015; WCB: G1078858


Hauppauge, NY 11788


03/09/2016 97140 2 $65.14 0 0 $0.00 $0.00 1e, 13,C8.113,C8.114

03/16/2016 97014 1 $20.48 0 0 $0.00 $0.00 1e, 13,C8.113,C8.114

03/16/2016 97035 1 $15.40 0 0 $0.00 $0.00 1e, 13,C8.113,C8.114

03/16/2016 97110 2 $61.14 0 0 $0.00 $0.00 1e, 13,C8.113,C8.114

03/16/2016 97140 2 $65.14 0 0 $0.00 $0.00 1e, 13,C8.113,C8.114

03/21/2016 97014 1 $20.48 0 0 $0.00 $0.00 1e, 13,C8.113,C8.114

03/21/2016 97035 1 $15.40 0 0 $0.00 $0.00 1e, 13,C8.113,C8.114

03/21/2016 97110 2 $61.14 0 0 $0.00 $0.00 1e, 13,C8.113,C8.114

03/21/2016 97140 2 $65.14 0 0 $0.00 $0.00 1e, 13,C8.113,C8.114

03/23/2016 97014 1 $20.48 0 0 $0.00 $0.00 1e, 13,C8.113,C8.114

03/23/2016 97035 1 $15.40 0 0 $0.00 $0.00 1e, 13,C8.113,C8.114

03/23/2016 97110 2 $61.14 0 0 $0.00 $0.00 1e, 13,C8.113,C8.114

03/23/2016 97140 2 $65.14 0 0 $0.00 $0.00 1e, 13,C8.113,C8.114

03/25/2016 97014 1 $20.48 0-0 0 $0.00 $0.00 1e, 13,C8.116

03/25/2016 97035 1 $15.40 0 0 $0.00 $0.00 1e, 13,C8.116

03/25/2016 97110 2 $61.14 0 0 $0.00 $0.00 1e, 13,C8.116

03/25/2016 97140 2 $65.14 0 0 $0.00 $0.00 1e, 13,C8.116


CMC



Hauppauge, NY 11788


03/28/2016 97014 1 $20.48 0 0 $0.00 $0.00 1e, 13,C8.116

03/28/2016 97035 1 $15.40 0 0 $0.00 $0.00 1e, 13,C8.116

03/28/2016 97110 2 $61.14 0 0 $0.00 $0.00 1e, 13,C8.116

03/28/2016 97140 2 $65.14 0 0 $0.00 $0.00 1e, 13,C8.116

03/30/2016 97014 1 $20.48 0 0 $0.00 $0.00 1e, 13,C8.116

03/30/2016 97035 1 $15.40 0 0 $0.00 $0.00 1e, 13,C8.116

03/30/2016 97110 2 $61.14 0 0 $0.00 $0.00 1e, 13,C8.116

03/30/2016 97140 2 $65.14 0 0 $0.00 $0.00 1e, 13,C8.116

Obj/Note Description12d Maximum daily allowance applies – PM & R Ground Rule # 11 and Chiro PM Ground Rule # 3

(12.01.2010).13 Please see note in comment box below:

1e Treatment Authorization was: exceeded, denied OR never requested by Provider prior to renderingtreatment.

C8.113 Treatment was not based on correct application of Medical Treatment Guidelines. C8.1 will be filed or hasbeen previously filed for this issue. PAYMENT DENIED.

C8.114 Treatment deviates from the Guidelines without securing a Variance. C8.1 will be filed or has beenpreviously 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 forthis issue. PAYMENT DENIED.

C8.116 C8.1 Filed: Variance denied without claimant timely requesting review, OR Variance denied by Boarddecision. Payment Denied.

MC The fee for this line has been discounted per the contracted rates with MagnaCare PPO. Questionsregarding the discounted rates should be directed to 877-624-6209 YOU MUST USE OPTION 3 to reachthe proper department.

Comments: 1) The variance granted was for physical therapy 2x a week for 4 weeks to the left shoulder. Date of service3/4/16 represents the third visit in a weeks time. Treatment rendered was not to the variance. Therefore, payment isdenied 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, "Thevariance requested in the MG2 filed on 3/24/16 is denied."


CMC



Hauppauge, NY 11788

Claim Examiner Comments:

Balance Billed: $1,621.60Balance Allowed: $90.00Previously Paid: $0.00Balance in Dispute: $1,531.60

A check will be sent under separate cover for the "Amount Allowed". All fees paid according to the NYS WCB feeschedule.

Claims Examiner: Jessica CarusoTel: 631-853-4954

Date: 08/31/2016


CMC


the enclosed wcb form(s) (c8.1b) and/or (c8.4) have been ... · c8.1 will be filed or has been...

Documents