po box 6100 hauppauge ny, 11788 do · po box 6100 hauppauge ny, 11788 ... po box 6154 church street...

Suffolk County Risk Management PO Box 6100 Hauppauge NY, 11788 NY Presbyterian Hospital West--- PO Box 6154 Church Street New York NY, 10249 Date of Letter: 05/05/2015 Date of Invoice: 03/11/2015 Date Invoice Rec'd: 03/16/2015 Date Resubmitted: 05/01/2015 Provider Federal TIN: 133957095 Point of Service: 10032 Regarding - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Patient Name: Cuiffo, Christopher Date of Injury: 06/14/2007 CC#: 2W700675 WCB#: 40706420 Code Description 416.8 CHR PULMON HEART DIS OT D/O/S CPT Bill Unit Billed CPT Allow Unit Allowed Prv. Paid Obj/Note 02/18/2015 75561-TC 1 $1,050.23 75561-TC 1 $1,050.23 $0.00 02/18/2015 A9579 1 $222.48 0 0 $0.00 $0.00 11k, C8.41 Obj/Note Description 11k Tech Component (--TC) includes personnel, facility, space, equipment and materials,including ordinary contrasts, drugs, film etc. Radiology Ground Rule # 6B. Additional fee charged is excessive, or not in accordance with pertinent NYS Medical Fee Schedule. C8.41 C8.4 Filed, amount of bill is excessive. Comments: Claim Examiner Comments: Balance Billed: $1,272.71 Balance Allowed: $1,050.23 Previously Paid: $0.00 Balance in Dispute: $222.48 A check will be sent under separate cover for the "Amount Allowed". All fees paid according to the NYS WCB fee schedule. Claims Examiner: Ingrid Simnowitz Tel: 631-853-4413 Claim Id: 157116 CE: Ingrid Simnowitz Page 1 DO Cuiffo, Christopher; DoA: 06/14/2007; WCB: 40706420

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Suffolk County Risk ManagementPO Box 6100

Hauppauge NY, 11788

NY Presbyterian Hospital West---PO Box 6154 Church Street

New York NY, 10249

Date of Letter: 05/05/2015Date of Invoice: 03/11/2015Date Invoice Rec'd: 03/16/2015Date Resubmitted: 05/01/2015Provider Federal TIN: 133957095Point of Service: 10032

Regarding - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Patient Name: Cuiffo, ChristopherDate of Injury: 06/14/2007

CC#: 2W700675WCB#: 40706420

Code Description416.8 CHR PULMON HEART DIS OT

D/O/S CPT Bill Unit Billed CPT Allow Unit Allowed Prv. Paid Obj/Note

02/18/2015 75561-TC 1 $1,050.23 75561-TC 1 $1,050.23 $0.00

02/18/2015 A9579 1 $222.48 0 0 $0.00 $0.00 11k, C8.41

Obj/Note Description11k Tech Component (--TC) includes personnel, facility, space, equipment and materials,including ordinary

contrasts, drugs, film etc. Radiology Ground Rule # 6B. Additional fee charged is excessive, or not inaccordance with pertinent NYS Medical Fee Schedule.

C8.41 C8.4 Filed, amount of bill is excessive.

Comments:

Claim Examiner Comments:

Balance Billed: $1,272.71Balance Allowed: $1,050.23Previously Paid: $0.00Balance in Dispute: $222.48

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

Claims Examiner: Ingrid SimnowitzTel: 631-853-4413

Claim Id: 157116 CE: Ingrid SimnowitzPage 1

Cuiffo, Christopher; DoA: 06/14/2007; WCB: 40706420

Suffolk County Risk ManagementPO Box 6100

Hauppauge NY, 11788

Date: 05/05/2015

Claim Id: 157116 CE: Ingrid SimnowitzPage 2

Cuiffo, Christopher; DoA: 06/14/2007; WCB: 40706420

Suffolk County Risk ManagementPO Box 6100

Hauppauge NY, 11788

NY Presbyterian Hospital West---PO Box 6154 Church Street

New York NY, 10249

Date of Letter: 05/05/2015Date of Invoice: 03/11/2015Date Invoice Rec'd: 03/16/2015Date Resubmitted: 05/01/2015Provider Federal TIN: 133957095Point of Service: 10032

CC#: 2W700675WCB#: 40706420

Code Description416.8 CHR PULMON HEART DIS OT

D/O/S CPT Bill Unit Billed CPT Allow Unit Allowed Prv. Paid Obj/Note

02/18/2015 75561-TC 1 $1,050.23 75561-TC 1 $1,050.23 $0.00

02/18/2015 A9579 1 $222.48 0 0 $0.00 $0.00 11k, C8.41

Obj/Note Description11k Tech Component (--TC) includes personnel, facility, space, equipment and materials,including ordinary

contrasts, drugs, film etc. Radiology Ground Rule # 6B. Additional fee charged is excessive, or not inaccordance with pertinent NYS Medical Fee Schedule.

C8.41 C8.4 Filed, amount of bill is excessive.

Comments:

Claim Examiner Comments:

Balance Billed: $1,272.71Balance Allowed: $1,050.23Previously Paid: $0.00Balance in Dispute: $222.48QRC Due: $0.00

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

Claim Id: 157116 CE: Ingrid SimnowitzPage 1

Cuiffo, Christopher; DoA: 06/14/2007; WCB: 40706420