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THOMAS N. GANIARIS, ESQUIRE
IDENTIFICATION NO: 59316
1930 ROUTE 70 EAST, SUITE K-56
CHERRY HILL, NEW JERSEY 08003
(609) 751-0070
ATTORNEY FOR PLAINTIFF
MED-FAST INC. &
BERNICE TAMBASCIA,
Plaintiff
CUMBERLAND COUNTY
COURT OF COMMON PLEAS
v.
KEYS'l'ONE HEALTH PLAN EAST
No. 1(' .:1Yf(l (l~u'~~,
Defendants.
NOTICE TO DEFEND
:'IOTICE
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COURT ADMINISTRATOR
CUMBERLAND CO COURTHOUSE 4th FLOOR
1 COURTHOUSE SQUARE
CARLISLE PA 17013 3387
(717) 240 6200
~
.
,
plaintiff rendered professional services to Mr. Culmer. On or
about August 21, 1994, plaintiff rendered professional services to
Mr. Schmidt.
4. On their respective dates of service, Mr. Culmer and Mr.
Schmidt each executed an Assignment of Benefits form which
,
authorized defendant to make payments to MED-FAST, INC. for any
services furnished to him by MED~FAST, INC. See Assignment of
Benefits forms attached hereto as Exhibit A.
5. Plaintiff provided various services to Mr. Culmer and Mr.
Schmidt, and also supplied each patient with a Gradient Pressure
Lymphedema Pump, as prescribed by Dr. R. Anthony carabasi, III,
M.D. See prescriptions attached hereto as Exhibit B.
6. The purchase of the pump for Mr. Culmer was pre-approved
by defendant under Authorization Number A0449495. The purchase of
the pump for Mr. Schmidt was also pre-approved by defendant under
Authorization Number B0450143.
7. In accordance with the Assignment of Benefits forms
executed by Mr. Culmer and Mr. schmidt, plaintiff expected payment
from defendant for services provided to the Insureds. Plaintiff
subsequently billed defendant for services and the units provided
to each patient, as assignee of benefits for each patient. See
copies of health insurance claim forms attached hereto as Exhibit
C.
8. While defendant reimbursed plaintiff for some items
billed, a balance of $7,000.00 for each lymphedema pump remains
long overdue, for a total of $14,000 due and owinq to the
plaintiff.
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MED-FAST, INC.
123 N. MONROE AVE.
CHERRY IIILL, N.J. 08002
1-800-523-6730
ASSIGNMENT OF.BENEFITS
I request that payment of authorized Medicare, Medigap, or third
party insurance benefits be made either to me or on my behalf to
MED-FAST, INC. for any services furnished me by this supplier.
,
I authorize any holder of medical information about me to release
tc,' the Health Care Financing Administration and its agents or
respective Medigap or third party insurance carrier any information
needed to determine these benefits payable for related services.
to be used in place of the
DI\'!'EI 081d.3~
. PA'l'IENT INFORMATION ~ tv' '
NI\MI'l G-g-'JQ(~ 1+, r. L( LJnfJ:f.@'F DOB Idlllo( ::16 PHO~E (OJ16 );;>35.1..:;/13
ADDRESS 311 ~ UJbs,T!Y1WT /h.E,CI'r'l ~ STA'l'E 81-ZIP I (..7 1.;7 )
PIIYSICIAN!s) ])r<. ~s::r:: IDA/CASE. 1"'6:J.-ao- (CJ;;).<6A ,
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Dr. flDDRESS 11~ -S" Ill1+-~;:-O'l'HER INS./MMW 18:J..BO/(~;)'<6~()
..TJ'.\-ILA) fA ADDRESS):<e-XST'lYJ6' tc5
REFERRAL I Dr. PI:. I. 6 ,;L (::.;. 0/0 ,,;J, p) 0 ()
'REPI ,'6E-R~ ,'t.t=- /_;;- '.-6
I permit a copy of this authorization
original.
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PHONE ",
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PLEAISE
DO NOT
STAPLE
IN ~HIIS
AAEA
,lItP"OV(1} O~D 01131 OQO'
rrnpoeA PICA rTI
t. fIlIDlc""1 MID_CAlC Ctl"~"UI:l CH"''''PVA UfIOV" 'ICA OTHI~ I' INSURIO Ii I 0 NUMUI!.R l'U" P"Vt.j/\A"'I,..It~1IoI II
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eV~HER GEORGE H rr ! 1~0 ! 'f~ ... It] "PI-1., S.It.
I. 'ATIIN1'I ADDAUS I~Q" lu"'1 .. ,,,TIINT RlLATIONSHI' TO INSURED 7. IN$lJJlIO a ",OORUS (NQ., 11".11
311~ WESIHONT AVE. ..It fKXl B9o\I..n Ch1lcln OI/'I.,n S.1t
e,lV IltATI .. ,AflINT ITATUI "'IV 'ITArl
PH1~A PA .......0 """'"0 ClIh<'(gl
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KEYSTONE HEA~IH P~AN EASI 182201~28 00
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It, OTHIR INSURlO'S OAtl all BIRTH SIX b AUTO ACCIDINn PLACltSIII.) b, EMPLOYER S NAME OR !fCHOOI.. NAMI
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c.IMP!.O E \Jl SCHOO.. N"IIlE ~ OlHIR ACCIOEN'f? c. INSURANCE PLAN NAME OR PROO"MA NAMI
PHt~AOE~PHIA, PA 19101 Om ~NO
o. .NSUA.ANCI PI"AN NAMa OR PROOR.AM NAMI '~RI5IA~60fORLocALU5E d, IS THERE ANOTHER HEA!.TH BENEFIT PLAN?
f. 0, 8oy:: 13 3'1 r:J YES o NO "yn, rll\lm 10 .nd r'lmpllt, It.m . I d
MUD lAC"," 0' 'artM lI,aAi COMP!.' TlNQ . SlaNINa TUII 'ORM, 1~ l~lSUAEO S OR AUTHORIZED PEnSONS slam,TunE I 'villa""
';1. /l'AtIINTS on ^UTHOntllO Pln50N S SIONATURl IlYlhO,IU U', ,,1..., ol,n, ml'dlCaI Of gUl., Inlo/mltlan ilK....,., P'~""I/\I 01 mtltlCl1 b.n"Il. 10 11'1. Und".IQned pn,I~'f1 01 .VP9"" 10'
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14~rl Or-CURRENT. ~ ILltlE55 1'''lt ',mnlllmj OR l!l IF PAl lENT HA$ HAD S.-ME QIl51MIlAIlIlLNES5 \".PA'E5 PATIENT UNABle TO WORt( IN CUnF1ENr acr.VfI""IVI'i
I f! I ,. INJUnV IACCld.nll OR OI"E FI~5 T CArl ~~:ft':ll MM I CO I Y'r' MM , 00 I n
I. I PRIUNANCYILt.lPI FROM I' TO I I
17, N.AMI Oil REFIRRINO PHYSICt~N OR OTHlR SOURCE '1111.0 NUMBER Oil Fllf(RRINQ PHYSICIAN II. HOSPH"LIl,ATION OAfES 1llLAtEO '0 CURRINT sERVICIS
eARA8ASI, R. ANIHONY e29347 MM1COIYV flAM I 00 I "
FROM i TO . I
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It, RISIRVID 'OA LOCAL U51 ~O, OUTSIDE. LAB? . CHARon
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/6/.0 . COOi ORlalNAL REF NO.
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"o~TfISI OF SERvtCETo PI". T,.. PROCEDU"u, SERVICES, OR SUPPLIES DIAGNOSIS "'c~ ;~~'I~ RESERvED 'OR
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;5. 'IDIAAL TAX 1.0. NUMBIR SSN IIN 21, PATiiN'Fi ACCOUNT NO. I ~CCEPT ASStONMFb;:.r? 28, TOTAL CHARGI 129 AMOUNT 'A10 30 ....L),NCI OUI
22-2mm n~ 21288 O'QO'llCillm,.," 01 ;1000,00 . 000,00 :tOOO ,DO
"'15 0 NO I .
~rUA' 0' PH'S'"'^N O. SUP''''A 32 'I.lMl! ANO "'OORESS OF FACILITY WHERE SERVICES WIAE 3J. P~l"'SICI"'NS, SUPPLIER S ell.l.lNO N"'~l, ADORUS, ZIP CCOI
UOINO OEGRIE$ OR CRl!OeNTI"'LS RENDERID III 011'11/ !hln hom, Ot orr~'l . Pt1CNI, HEHASI,INe,
I (I rllr~~llm.",'onlt'l'rh'/"
till I d .,.m'd,.parlltl""oll 123 HORTII HONROE AVENUE
.l~ 09/12194 CHERRY HI~~. HEW JERIEY 0~.;L
.,,,,0113080001 I 0"p.(~09) ~~/'~/30
I !!lInN 0 OArE
tLcd-u... ~-:I! 110 '1~9t/{)-S--
HEALTH ~ANCE CLAIM FORM
(A"fIIOVIO IV AMA CDU'lCtl. ON MEalCAL SIlR'ilCIi! 11111
PLEAse PRINT OR TYPI!
'DRM HC1 ".1100 t l;r 901
'OAM O'/llCI'.I500 'OA'-' "RI 1500
,0nM AM'" OP'O!')(IJt2
rrn'ICA HEALTH INSURANCE CLAIM FORM
hI. WIDICAAI,...... MECICAIO ....-, CHAf.l'UI nCHANflIVA,..,...., ~:~crH Pl.AN ~ '~;~lJNQ.-. OTHi~ , L INSURED 61l). hl.,lMUEA
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12. PATIINTS OR AUTHORIZED PIRSON'S SIGNATURE 11~,lhonlll1l. falun or lilY m~Ul or Olha' Inlormallon n.e"wy
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:)'.'101'1 ,t,MA COUNCIL ON MEOICAL SIRVIC' WI)
PLEASE PRINT OR TYPE
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4, INSUA~~'05 .tIAM.1 (:..1 Naml, 'Ir'l NIIIl., M,(Idll IrutllJl
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7.IN5URI0'1S ADO~US lNo., SV"11
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CITY I STATI
ZIP CODE -TTEi.(PMONI rCI.UC& A~IA COOl,
11.INSURiDS fO\.lCV CROUP OA fiCA f';I,JM8iR
i.,;'"
I ,
I. INSURIOIl OATI 0' "~TH
MMlODI'tY MD
D, EMPllJ'rEH & NAMa OA SCHOOL. NAM~
IIX
.n
e INSURANCE PLAN NAMI! OR PROQRAM NAME
1t,IS THERE ANOTt-lIA HEALTH BENI~IT PLAN?
DVES n NO "yee.r.lI.Imtaandcompleltl\l,.,,'14,
\3 INSURED S eR AuTHORIZED PE~SON'S SIONAn~RE I lutl'lQroll
p.~m.nl 0' m,o,clIl ben,lil' to lhe unct"llgntd p"~IICI&I'I Of Iuppll.' 101'
UI'IIC..ctIlCllladbetIlW
"
SIGNEe
Ill, OATIS PATIENT UN,t,&I.E TO WORK INCURAINT OCCUPATION
MM I DO I VY MM t 00 I Y"f
'ROM I I TO I I
II. HOSPIT,t,lllATION OATES REl.ATlD TOCURAINT SIAVICI,
MMICOtY"f MM,C01YV
'ROM I I 70! I
20, OUTSIDE LAB? 'CHAROn
0'65 0"0 L I
22, MeOICAIO RESUSMISSION
COOl! I ORIGINAL RE'_ NO.
23. PRIOA AUTHORllArlON NUMBER
, Q " , M
OR F.mll~ Af.SEAV(O 'OR
'CHARGIES UNITS PI~ IMO COI LOCAL us.
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21. f01Al. CAROl \2'. AMOUP'iT PAID 30, 8AVliCl Oul
. 7' ,- :(.I~. ':. -- , ' :." r,
l3. PHYSICIAN'S. SUPPLIER S 81LLING NAMI. ADOAnS. liP COCE
A PMCNIi. <, \! '. I') .. ..:';'
i;).~( ;..J ,"I.I~I.j"r: 1.,/1
..:,..,.f-r. ,. /11' /1 1_ r
PIN. -'1,"11/., I I~A". 'I','
'OAMHCF~,l$OO IIZ,tol
jl'ORM owep'o I 500 'OFlM RillS. I 500
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KlfYSIQnQ Huol\/1 Pllln Nt'^' JtHlU1y
DATI
03/22/95
NO CHECK
1
CHICK NUMBIA
r
MEIl FAST INC
123 N MONROE AVE
CHERRY HILL NJ 08002
-,
PACI N\JMIIA
L. ...J .
STATEMENT OF REMITTANCE
,...nlhf NNilliCONT'\Ol. NU"'QIR [ U~.I'. 0"". "'.... PAOCfOuAI COOl I .AMOIJNf BILL~OUNT .....l.OWIO. MIMIl" "1~pb~SI'IL!r, "~'OuNT '.lID I/lt...
.\0",,10". '000.., ....l_...!..
CULME~,GEORGE 082394 1 E0652 700.00 0.00 0.00 0.00 HOOl
2128B 082194 2 E0667 300.00 0.00 0.00 0.00 HOOl
OCNz 5J1t81030 100 092394 1 E0652 700.00 0.00 0.00 0.00 HOOl
092394 2 E0667 300.00 0.00 0.00 0.00 W007
. TOTAL. 2000.00 0.00 0.00 0.00
REASON CODES:
, HOOl
,; W007
THIS IS AN EXACT DUPL.ICATE TO A PREVIOUSLY PROCESSEO CLAIM.
ACCORDING TO OUR RECORDS, THIS SERVICE IS A DUPL.ICATION OF A
~EPORTEO SERVICE. DUPLICATION OF THIS TYPE OF CARE MAY NOT BE
OR ELIGIBL.E FOR SEPARATE REIMBURSEMENT.
PREVIOUSLY
POSSIBLE
"r.,I-. t.' ....1_
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YOU HAVI ANY QUISTIONS ABOUT THIS STATlMINT OF AIMmANCI, PLEASI CALL (215) 241,2060,
I
R PHYSICIANS. The Amount Allowed is determined .1 the least 01 lh. billed amounl. your usual charge, or ltlt Kevstone Health Plan conl5ullll'lg phy.iClan
program mlU:lmum allowance, II you are a Key.lone Healll'l Plan contracllng pnYSlclan, you musl .cce~ll'" Amount Allowed as payment'ln.lull,
A HOSPITALS. The Amount Allowed is detlrmlnld In accordanCI wIth Ii'll prnvlslons 0' your contrlCI With Key'lon. HillIn Plan
MlarMgs lor Inpali.n!. emergency, and ambulato') surgery 1'I0apllll procedure codoi art Prlnl'd on tn, back 01 lnls form
MINDER. DlrlCI all cllllms 10 Claims Oopar1m.nt. PO BOA 6~8815, Cornp HII:. PA 17001.997:)
I'.. ......IIl~... ..... Jl.t'IIW I "'.e..~. ,.'~!J" I', L" .~..,. " ,,". .....0 I
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BIiU.1.t,U.;.u E..QB B~lt.\ol. E.9Bt1
Fruml M.d-F..t, Inc.
123 N. Monroe Ave.
Cherry Hill, NJ oe002
ProvicJtlr III tl.:? :2111'-/65
"
Tu: h~'5r(IIJC f!e7;t.m r>c.mv 64-8r
C-L.;t" rY1 '::> ~(r)e-.rr
(.7, 0 ' (:Jx;ye <il'l'3 ~J' 6
:c..A-m e H1' II, (If). 110~q -~<616
PaLiellt'e Name: G-ES=OI2(~ Cu..Lrn'a:,~ 1<j~';).()/&.J'6,:;o
Wale of Service: IO/.,;J.3!q<-/ Procedure code t €C1t;.S.;J, cc.'f.:t, '1
lJiawnosill code: '75 '7,() Tqtal Charges: ..1/ 7C>CiO. l~)
.. lCNII: 1-:;'017 ;>3 /.;;)00
.
Review Explal1ation: (Ju....r(" I Ll ~ fY'\ LUf<t'<.. PR...E...,.4-PP((DV/3{) H;i.!...
p~ I1'/{ if f Uvnd ~,v- (J.A.A._+h -1F AO'!4-q t../-q 5. (t~E" ecc H~;:,cL.
~Ol:,vY'.h l~ FbR. T1-hS .:r.Nt=CJ(2(nWr7'C'~c.t k,'Nbl1 pRO(~r'~
o lA-V'" r~ ()r) ~R. P04 m e==N1 ~ f-t-C::n2fE:6 . v~'C. U.J'c.J'....:c_
:I::.N<;, -re, (A c.TC-t::; ..,-0 81 U..... /)..I-r?S~ J. TC='I'?? S C'L.{ r ~ I~V :-1-l{.
Pot<. .,.:; I'??()/L) ~ ~ ilfr=::N 4-'S.4 f-I.-<-R(! H--ri:'SE' A.> {. (. ," (,,-", _l./ ('"
Tf.h' ~ .:J /'7) 0 N rH Rrn ~L Pc.=rc /0 {). c.u6 I-f,qVE F()(t,{!~
Rel.luest.oy's Signat....r.: '- g~..I &G.u/~? )
[Jat.e: /III ~ / q '-f.- ',., ' ,
I '. .
1hf.::rL ~N S ne f.Afl. II oN S A-N [) 8,L f'E l!. -r T(.)
I,HrOl Rec.e:./ vG' --rH-6 S47nc {!.DDPFf2.A-.TUAl Fi2.(:rr/
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DATI
12/21/94
01311215
1
~-, "
MED FAST INC
123 N MONROE AVE
CHERRY HILL NJ 08002
CHICK NUtM."
'AOI HUM,,"
L
...J
STATEMENT OF REMITTANCE
. ~! CA ~ 10<1 P~OC(OUAI COOl .AAlOVNT 1I11..L!:D AMOLNT "'L.1.0WIO' "'tlll'IM A151JO/rr111111,1T'T AMOUNT '-&10 "
o\OloIl'O"" OOO<lol',
092194 1 E0652 700.00 296.50 0.00
092194 2 e0667 300.00 41. 00 0.00
102194 1 ,e0652 700.00 0.00 0.00 woe
102194 2 e0667 300.00 q.OO 0.00 woe
102394 1 e0652 6000.00 0.00 0.00 woc
102394 2 e0667 1000.00 0.00 0.00
, ..~, ..1.:.... .... J' 1 .,,".~ ,,',
',,,"liNT N.lMtCONfAOL NIJM81A
SCHMIDT, TIMOTHY
DCN-43337960500
CULMER,GEORGE
21288
DCN-43406380300
.... ' '~,
TOTAL
9000.00
337.50
0.00
REASON CODES:
W009 SERVICE NOT PRE-APPROVED THROUGH KEYSTONE BY THE PROVIDER. THE MEMBER
HAY NOT BE BILLED.
.. :'-:..t..---_...
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" YOU HAVI ANV QUISTIONS ABOUT THIS STATlMENT 0' REMITTANCE, PLeASI CALL (215) 241,2050,
POR PHYSICIANS. Th. Amount Allowed 115 dfl,rmln'd IS In, leaSl 0' Ih, billed amounl. your usual ,nargt. or Ine KlySlon, HUlin Plan Enl -;on&ulllnt. Pr'l~I'Clan
program maJumUm allowanCt. 1,1 yov Irt a K.ylIO'" HUlIn PIlln Eall conlra~llnQ phySICian. you must acctpt Ih, AmOunt AlIowtO as p.~mtnl-,n-fI..J'
'OA HOSPITALS. Tn. Amount Allowed IS dll.rmln.d In accoroanc. wltl'lll'l. provISions 01 your conlra~1 wllr'l Keyslon. Health Plan Ea.!
M.anll'lgl lor inpau.nt. .'"erg.ney, and ambulatory surg.ry hospual proc.dur. coOn Ire prlnlld on 11'1. OICM. 01 Ii'll' !arm
Dlrlet all clalmllo: Claima Otplt1m.nl. FJ,Q. Bo. e9881a, Camp Hill, FJA 17001.9973
. ,WC;v,:)LUHe
.., /HIA~fH "LAN lAP
,
r
MEO FAST INC
123 N MONROE AVE
CHERRY HILL NJ
-
+, OAT' 12/06/94
el1leK NlJM81N 01303814
-,
'A.a, NUM'rlll 1
08002
L
.J
STATEMENT OF REMITTANCE
"A'IINT NAAlIICONTAOI. Nl,JMBlR
"""'''O,UI.I ~'~M f;ROCiOl,JAI COOl ,t,MOlJNT 811.1.(0 .AMOUNT "LI.OWIC' "'1f.lIIA'IlII'ONIIIII.I?'Y "1.l0I.I'''' '1.10 ':to
AOIllITOAlI
08Z194 1 E0652 6000.00 0.00 0.00 0.00 WOl:
082194 2 E0667 1000.00 0.00 0.00 0.00 WO(
082394 1 E0652 700.00 296.50 0.00 296.50
002394 1 E0667 300.00 20.50 0.00 20.50
092394 1 E06,2 700.00 296.50 0.00 296.50
092994 1 E0667 300.00 20.50 0.00 20.50
9000.00 634.00 0.00 634.00
SCHMIDT, TIMOTHY
DCN=43218ge0100
CULMER, GEORGE
21208
OCtj=43216560100
TOTAL
REASON COOES:
W009 SERVICE NOT PRE-APPROVEO THROU~H KEYSTONE 8'1' THE PROVIOER. THE MEM8ER
MAY NOT Be BILLEO.
IF YOU HAVI ANY QUESTIONS ASOUT THIS STATEMENT OF REMITTANce, PLEAse CALL (215) 241,20eo,
;'OR PHVSICIANS . Tn. Amo\,lnl AIJQWlId II dtltrmlt'l'd aSlne Ita'1 011/'1, tI,1I'0 .JtnOl.lnl your I"iSI,lQI ,,,afQ,". or the Klyston. Healln PIGn enl COn,v1h"'i1 CrI,!i C tin
prO'llram mgJl'f"l\,lrl1 allowanc. II you art a K'Y$lon. Healln Plan EaSl conl'acl,no P"yslc,a" yOu mul' acclJPt I'" Amo,,"nt AIIO'.'Y.d ill CII,f".'1I .' ',.'
,:OR HOSPITALS. Th' Amounl AlIowea IS dflermln'd In aC<:oraan<.:, .....111'1 11'1, !:,rO'lISlonS Of ~"ur r:On!r8Cl wlll'\ K'yston, P'1.aIln P'ln Eut
M.anlngs lor In!:,'li'n!. ,m,rg,ncy. and amoul410lY SUfQ"Y t'lO!\CIIII prOC't.l.,.r, CO(JU Ir, Pflnl,O on In. O.C~ 01 II'\IS lorm
4IMINOIR. Olr'cl all claim, 10 Claim, O,p'11m,nl. FtO BOl S9S815, Camp Hili, PA 17001.997:]
,W ....HIAUt1 '~"I'f I"~f
+,
OAr,
11/08/94
NO CHECK
r
MED FAST INC
123 N MONROE AVe
CHERRY HILL NJ 08002
..,
CHIO( NVMII"
'AO' NUM'I~
1
'."
L.
...J
STATEMENT OF REMITTANCE
'AnINT NAMliCONTAO~ NYM.IR ':')ID~' ~\:.\ PAOCIDlJAI COOl AMOYNT III.LIO AMOUNT A~~OW(O. lll,MIEAAISltQhlIIIU"" AMOVN"AlC '"
"
(,UL.MER,GEORGE 10Z394 1 EC65Z 6000.00 0.00 O.CO O.OC wec
~lZ8B 10Z394 2 E0667 1000.00 0.00 c.OO o.co WOO
OCN-1t3017231200
TOTAL. 7000.00 0.00 0.00 0.00
"
REASON COOese
101009 SERVICE NOT PRE-APPROVEO THROUGH KEYSTONE 8Y THEPROVIOER. THE MEMBER
MAY NOT Be BILL.EO.
,..,
',"
'.,.f"".......,..
... ." -,.>< .. ," ,w.", .,.,.... ~\o".. , .. .
,-t.','
,~:. .
, ,
, YOU HAVI ANY QUISTIONS AIOUT THIS STAUMENT 0' REMITTANCE, PLEASE CALL (215) 241'20eo,
:OR ..HVlleIAN.. Th, AmCllmt AlIOWtd III dtt.rmlned II Int ltast 01 In, Olll'd amounl, VOIJf U$ull ChafQ', Of In, K.ystone HeaUh Plln lilt Conllollllng P"YIICI,n
j;lrogr.m m<mlolm III0wlnce II Y,OU If. . Kevstonl HUlin Plan EaSl COnltlC\lnQ pnY'IClln, you mlolll aCCeptl"t Amoynl Allow'd II r;llymlnl'lnflolll
'OR HOI'''ALI . Tn. .Amount AIloWld II dltlrmlned In accordance wilh In, prOYI!llons or your conlract with K1vstO", H,allh Plan East
M"M1Qllor Inp.ll,nl, em.rg.ncy, Ino .mClulllOry l'wrgerV MOlp1111 l)'OClO'wr, COCtI "' pMIICl on I", CICK Ollt'l., 'Olm
IIM'NO." . Olr.el.1l el'lm. 10 CIIIrT:1 Otp."m'"I, PO Ho. 898815 Camp HIli, PA 1100"~97J
-. .
, :
RJ;...~I,J.!,:~J, f.OH ~1;:y"1.f;,lo/ E.C).flt.1
From: Med-F..t, lnc.
123 N. Monroe Ave.
Cherry HilL, NJ 08002
proviutlr III e itJ.tf !J;;J,().QQ1fS5
Till .KEt{<;rolJc l-ttcf-lL'rl+ PLA1J ~I
(2, ()~Qk ';{~i g 15 _
CiftnP 1-h'111 fA 1'70<61
'.
f'dLienL's Name: -11 ~ar~ ~ Iffi.l9.r- ......11:
uate of Service' ~ Procedure codel
ul4lolnosis eQue: 15'7,0 Total Charges:
leN..: ^4 A
.I~::J .30'7 qo;J.W
~Oi,5:X , r::o&01
.JI7 (){) 0 . (Fe>
Review Explanation: / to a/// I "".-L. . .
" ~ __ Ic:'~ _.eu.I,- <..-
, .~), -,.r/' ~ . ;' / ' I
t. , 1'1od~' .., ,./
c' cltL.tA~t<..9:( (},Jv/fJ",!3A.dk L1A" ~'UJtAL~/( ~:tL:1lJ L; .{<:.
~'-c1/((fl(E/:j~~'C;k/~,~jJ.}.I <<~.~~ L/i/*:~tf~:
:J!'~(f ~ /!!".2~ /~'t~~~ d,)?4-,~, 0
~J:;f~l tU ,&;,,)'-<.-,;t#.-,,_dr.-C..LJ"'ttA-J. J ~/t..-J'-<H ~l-.y;[; f (
r'R:,-\uesLor '15 Signeture: ,4..-?L~U.A'"-.t
(Jete: .9iliJ..? I
"
IJ ;'~"";o-i# ":(/J~dJ ?""- .A.Lt2k-,' ~,~;,
(41(,oi.(.L;-/t.t,. t!d r 1-':fJ?I~4t./, S2,,--..v.... ~~''''I I<-h..-/I~
.
, ,W\.;Y.)l.UU\....
W .IMI"'~hl '~fo"'~
OA'.
CHIC... "'I..M&I~
r
MEO FAST INC
123 N MONROE AVE
CHERRY HILL NJ 08002
-,
''''01 NU~.'1lI
L
.J
STATEMENT OF REMIITANCE
'AfIINT NAMliCCNTjl!OL. NUM81R PROCIOURE COOl
SCHMID T, TIMOTHY 112194 1 E0652
112194 2 E0667
DCNa50613770400 092194 1 E0652
092194 2 E0667
102194 1 E0652
112194 2 E06b7
.. _... l
KdYIUO'HJ HUlln PI." Nww Jill''')
03/28/95
NO CHECK
1
AMOUNT BiLLIO AMOUNf ALLOWIC. "'EMil A RUPONSl81UN .wOUNT 'ollO
~t~
,',
6000.00
1000.00
700.00
300.00
700.00
300.00
TOTAL
9000.00
~...)-..).J,~
f'~l"
0.00 0.00 0.00 W084
0.00 0.00 0.00 W084
0.00 0.00 0.00 HOOl
0.00 0.00 0.00 HOOl
0.00 0.00 0.00 WOO~
0.00 0.00 '1.00 WOOS
0.00 0.00 0.00
REASON COOES: ~ ~U..l>O~..J
PURCHASE DENIED BASED ON AUTHORIZATION. RESUBMIT SERVICE AS A RENTAL.
THIS IS AN EXACT DUPLICATE TO A PREVIOUSLY PROCESSED CLAIM.
SERVICE NOT PRE-APPROVED THROUGH KEYSTONE BY THE PROVIDER. THE MEM8ER
MAY NOT 8E BtLLEO.
1/084
H001
1/009
'.'
~." , ,....
,
If YOU HAVE ANY QUESTIONS ABOUT THIS STATEMENT Of FlEMITTANCE, PLEASE CALL 1215) 241,2050.
'OR PHYSICIANS. Tn, Amount AUowla 15 d.ltrmlntd as In. leas! ~I lhe 0111,0 Jrnounl, yQ{J( 1.1'1.131 cnarljlt. or the Keystone ~1',),1'" Plan conS\,.illlno pnY'lClon
program ml1.Jlul'lum aUowanc. II ~OU art J KU,SIOt11t HIJa:lh PI<lr' f;un1raclmg Pl'1yslc1an 'jOU rtlust ace, pi tn, "-rroun! Alloi'l.a as paym.nl'IrHI,1l1
'OA HOSPITALS. Th. Amount Allowed It C1.lermln./J In aCCOldar1C' >o'\'llM 11'\. prO'l'I~IOn, ot '/0....' COMaCl ",ilrl K..,..'lon. Mealin P'ln
Meanlngl lor lnpatl.nt, .merQlncy. and amouhJlory surglry n05~:lIt.J1 procedure COd" ilre prlnl.d on lne caCk 01 !nl' torm
..IMINOIA. Direct aU claims to Claims D.p.nm,nl. PO BO.8988" Camp MIll. I-'A 17001.9973
._...._.......... '."., ,......~ '.' '''~'. ~~,.,'. I"". u'.'"
",IjVlilOntl MliOlln Pllln NliW J.r'tlV
OAre
03/07195
NO CHECK
r I
KED FAST INC
123 N MONROE AVE
CHERRY HILL NJ 08002
CHICK. NUMBIR
'.01 NU~.IA
1
L
.J
STATEMENT OF REMITTANCE
'''f1INT NMlE.CONTROI. N\,IMBe:~ J'AOCEOVRI CODE AMOVNT BILLED .-MOWN' "UO'^e:O. MII,l8lR' RESP()"'ISIBI~If'Y AMOUNT '....0 ~t~
SCHMIH, TIMOTHY 092194 1 E0652 700.00 0.00 0.00 0.00 HOC
092194 2 E0667 300.00 0.00 0.00 0.00 HOt
OCN= 5~ 481 030200 102194 1 E0652 700.00 0.00 0.00 0.00 woe
112194 2 E0667 300.00 0.00 0.00 0.00 woe
TOTAL 2000.00 0.00 0.00 0.00
REASON CODES:
HOOl
W009
THIS IS AN EXACT DUPLICATE TO A PREVIOUSLY PROCEsseo CLAIM.
SERVIce NOT PRE-APPROVED THROUGH KEYSTONE BY THE PROVIDER. THE KEMBEh
~AY NOT BE BILLED.
I' YOU HAYE ANY QUESTIONS ABOUT THIS STATEMENT OF REMITTANCE, PI..EASE CAI..I.. (215) 241,2060,
, 'OR PHYSICIANS. The Amounl Allcwea IS aetarmmed as lne leaSl 0' Ire billed amount yout uSlJol r.notge, Of ln~ KeY'Jlcne ~Na.(" P';ln CQflSullinQ PhY'SI";I;\n
program ma)UmwlT'l aII0....,an'8, II you are a I'\~~stcne He;,llh PI(J1l ccnlracllng pnl$ICh.\n. 'IfJU mu'Sl acceplth(' An1QI../'1 AII(..Y.~'J a~ pa,I"Vrll"n'!u,1
'OR HOSPlTAL.S. Th. Amounl Allowl!d IS aetermlned In accoraance Wllh the ~rOvISIOJlli 01 Vour contract Wlln KOYSlone Healtn Plan
Munmgs lor mpallijnl, emergency, and 3mCulatorv surQery ho!pllal procedure code! afe printed on 1M oaclo: 01 tnls lorm
REMINOIA. Oirect all claims to Claims Oepanment, PO Bo. 698815. Camp l'iIU, PA 17001.9973
"-ytlor. MHV.I"I... '.." JtlUy 1m.."" ..,j""l." II, C" "",.~" "_"'.. ,-'_It:)
, ~ . '-') ..,~v....'-'
W HIAl.TH ".AN$
-. .
1\11'''''.....'.''' 'HOI""" . ....', ..",U ...\01' ~"I
DATI
CHI~I( NU'-A8l~
01/25/95
NO CHECK
r I
MED FAST INC
123 N MONROE Ave
CHERRY HILL NJ 08002
'Aar NU....."
1
L.
..J
STATEMENT OF REMITTANCE
'AnINT ~4AMIICONTROl. Nu~8IA
$~~~f,.Oc:.'.L' ~ 'Joe,', PAOCEDIJ/l.. COOl
AMOIJ~T IJn.I.IO AMOUNT A1.1.0W10' Mlttiel" IIlUPOt.SlltuT'r
;.MOV,d PAlO
.,
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SCHMIOT,TIMOTHY
DCN"5009io3io0100
112194 1
112194 2
E0652
E0667
6000.00
1000.00
0.00
0.00
0.00
0.00
0.00 W08'
0.00 W08,
TOTAL
7000.00
0.00
0.00
0.00
REASON CODES:
W084 PURCHASE DENIED BASED ON AUTHORIZATION. RESUBMIT SERVICe AS A RENTAL.
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I~ YOU HAVI ANV aUISTIONS ABOUT THIS STATlMINT 0' REMITTANCE, PI.EASE CALL (215) 241,20eO,
'OR 'HYIICIANS . The AmOUr'll Allowed IS dll'''''1Inld IS 11'11 leaSI 0111'11 blUed amount. your usual CMfg., Of U'Ut KeystOne Heall"" Plln con,ullll'lQ pl'lvtlClln
program ma.wlmum allowl1nCI II '1ou ar, a KeyStOne Healtt! Plan COr'llraClln.; p/'lyslc1an. yOy muSl aCCqp\ 'he Amount Allowed I~ PI'tment'ln.tu.1
FOR HOSPITALS. Tnl Amount Allowea IS dttlrmlnlld In lJccorclaf'Cll' wlll'llt'le prOVI,&ICI'1S 01 your con!raCI 'Nltt'l K.ystont Healll'l Plan
Me.nlngs lor Inpalllnt. emergln<:y. and lJmev1llory surgery hlJSpll!1 prOCltclurt COdes Ire prtnl,a on It'Ie Cack of tnll IQrm
\' "IMINO.... C'llrtct III <:llim, to CIII"'" Olp."m,nl, PO BOll 89881~. Camp HUI, P"" 17001.9973
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-tv 0""10' 12/21/9,.
CI-lIC~ I'4\JMIJIA 01311215
r -,
MED FAST INC 'AOI froIU......" 1
123 N MONROE AVE
CHERRV HILL NJ 08002
L.. ..J
STATEMENT OF REMITTANCE
Il'AnlNf NAMfJCQNTPoOI. Nl,IMIIA I "~I /I ~,.(', ItIflOCIOU~1 COOl AMOUNT IIU,IO MlO"Nl' "1.1.0..,.(01 MIMI'" l'U..c....,.Urr AMIJV'" ,I.IC I":
..01,10 OA' ~" _..u
SCHMIDT, TIMOTHY 09219,. 1 E0452 700.00 294.50 0.00
09219,. 2 E0667 300.00 41.00 0.00
OCN..43337900500 10219,. 1 e0652 700.00 0.00 0.00
10219,. 2 e0667 300.00 0.00 0.00
CIILMER,GEORGE 102394 1 e0652 6000.00 0.00 0.00
21288 1023'1" 2. E0667 1000.00 0.00 0.00
OCN..,.3,.06380300
TOTAL 9000.00 337.50 0.00 33 7.50
'REASON CODES I
W009 SERVICE NOT PRE-APPROVED THROUGH KEVSTONE BV THE PROVIOER. THE MEM8ER
MAY NOT BE BILLED.
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"YOU HAYI ANY QUIITIONI AIOUT THIIIITATIMINT 0' IlIMI1'TANCI, 'LUll CALL la1l1 241.aOIO,
I FOR 'HVlleIAHI . TM "mOynl A110w.d " dtl.rmln'd .. I'" I"" of I'" blU,d ,mount It'Jur UIUII r,n.,o. ~, ,,,, I<'V'IOI'I' "I..lln 11I1," hll (Onll.lIMQ P"v',C 0'"
p,oQ1am ma.llmum l\lIcw8nc. II yQU art a K.'{Slon, H,om'l 1'111\ I!,I'~I ';'jl'IIUr.I'H'J ~"'I"(>l11I IW'J fTlIJ,1 ..te,pllh. ,A'T'i.'J,'1 ;. '1..111') II' '.'I,-"It"(.r '"
. !fOR HOSPITALS. Thl Amounl AIIO'hld II ~""mln.d In 'C:C:Qf(Jlru:e WIIM 11'10 P'tj~IIIOI'~ 01 1'~lJl 1;0"111" "'11M 1'\",'10'" HIrfI)III' IIllIlII Sotal
Meaning. lor InQi<,nl, ,m"o.nc:y. anll BtN'\,,1iI110fr' 'lo'ytf''! t'10IUj,l'JII;")~~IJ"'tl ,:r.l1U Ill' l).,r'I"'J t;;/1If1I1I:iO (jll"'~ ',,(11'
. REMINOE". OlflCIIU Cllll1lltO; CI.,ml Otplt'1mtnt, PO 80. ij98ij\!). CalnjJ HIli. PA ''''OOl.<jIH:J
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11/15/91t
NO CHECK
CHICK NUM""
r I
MEO FAST INe
123 N MONROE AVE
CHERRY HILL NJ 08002
'AGIIIUM.11lI
1
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STATEMENT OF REMITTANCE
'''TlINT NMlIlCONTROl. NUMBIA ~~~lco,.~~lJ 1tO,.(l PROCECIJAI COOl WOUNT BII.LEO AMOUNT "1....0wI0. 1lI1....IAAIS!JON5IBII,IT'I' ""'OUNT ~"'IO :'~ .
~1lO'1 ..'
SCHMIOT,TIMOTHY 062194 1 E06$2 700.00 0.00 0.00 0.00 WOO,
062194 2 E0667 300.00 0.00 0.00 0.00 WOC.
OCN:0430581t40400 062194 1 E0652 700.00 0.00 0.00 0.00 WOO~
062194 2 E0667 300.00 0.00 0.00 0.00 WOO~
.000.00 0.00 0.00 0.00
REASON CODES:
W009 SERVICE NOT PRE-APPROVED THROUGH ~EYSTONE BY THE PROVIOER. THE MEMBER
~AY NOT BE BILLED.
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, YOU HAV. ANY QUESTIONS ABOUT THIS STATEMENT 0' REMITTANCE, PLEAse CALL (215) 241,2060,
:OR PHYSICIANS. Th. Amovnl Allowed IS d.t~rmln,C1 as 1M least or lM Ollleo amou/"It your usual cnargt, or 11'1' K,ySlont ,.,'ealln Ptan EaSlconS\,jllln; pM','lc."n
program m/Lllmur" allowance II yOl,j ar, a ~eY$lon. 118alln plan Eas' cont/aCtlng pnysle;,a" ~ou 11'1..1'1 acell)1 me Amcunl Allo...ea lIS pa,r'M,r't ,n I...
'OR HOSPITALS. Tht Amoun! Allowed IS dfllrm'r'ltClIr'l aCCOrClIlr'lCI With 1M Qlovl510r'15 01 '1Cur COr'llract ....IIM KtystOnt HUllh PIa" Eas\.
M..nl"gs lOr Inplll.nl. emergency. and IITil)\JtltOry SU'li!'ry hospital prac.d...,r. COdts are pnnlld on lh. l'laCk 01 1M. lorm
leMINO.A. 0".'1'" ellImo to; C,"mo OOplllmlnl, PO eo. 89881\, Comp H'", PA 17001,9973
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10/18/94
NO CHECK
CHICK HUMI."
r
MEO FAST INC
123 N MONROE AVE
CHERRY HILL NJ 08002
.,
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1
L-
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STATEMENT OF REMITTANCE
_"'IINT NAMIiCQNTAOl,. hUM.I"
SCH~l)T, TtHOTHY
OCN-IoZ 718381100
'''OCIOURI COOl AAlOUNT 11l,.I.IO .-MOUNT ...""Owlo. hlllil..AllllpONlllllJTY MlOVN"AiO "fI'~
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062194 1 E0652 700.00 0.00 0.00 0.00 WOC'
062194 2 E0667 300.00 0.00 0.00 0.00 woo
072194 1 E0652 700.00 0.00 0.00 ' 0.00 WOO'
072194 2 E0667 300.00 0.00 0.00 0.00 WOO'
2000.00 0.00 0.00 0.00
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REASON CODESI
W009 SERVICE NOT PRE-APPROVED THROUGH KEYSTONE BY THE PROVIDER. THE MEMBER
~AY NOT BE BII.I.EO.
F YOU H.WI ANY QUISTIONS AIOUT THIS STATlMINT 0' RIMITTANCI, PLIASI CALL (2'5) 241,2080,
OR PHYSICIANS. TI'I. Amount Allowed 11 dtllrmln'd II the IUsl all'" CIU'd amount. 'IOlJ' ull.lal char'il" or It'll I<.yllon, HUlin Plln r;Onl\,jlhnQ QI'lYSICII"
program mll.lllmUm 11I0"",'I'lCI If yOu Itf . KftySt011, Hllllh I'll" contrQClInQ pt'l'l~.Cliln, yOu lTIutllcc.pllnt AmolJnl ,AIIOhllu .. plymonlln.l!"d
OR HOSPITALS. TI'l' Amount Alia......" IS dttt""lntq In ar,coroance ""111"1 tn. prO'flllons of yOur 1;onlfl1;1 WIII"1 K'VSlor,. HUllM 1'111'1
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,IMINO." . Olr.ct III clllm, 10 Clllm, O.panmtMl, I' 0 80. e988\~ Clmp Hilt, PA 17001.9913
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THOIlAI .. GAIIIAIU:., IIQUIRI
IDIX'1'IrIOATIOH NOI 5.311
1.30 ROUTI 70 IAIT, IUITI X-51
OHlRaY HILL, HIW JIRIIY 08003
CIO.) 751-0070 '
AT'1'ORHIY rOR PLAIHTlrr
KED-FAST INC.,
: CUMBERLAND COUNTY
COURT OF COMMON PLEAS
:
Plaintiff
v.
CIVIL ACTION
.
.
KEYSTONE HEALTH PLAN EAST,
No. 96-2850
.
.
Defendant.
"
NOTICE OF VOLUNTARY DISMISSAL
Plaintiff MED-FAST, INC., represented by Thomas N. Ganiaris,
~squire, having refiled this matter in Philadelphia County,
Pennsylvania, where the defendant's offices are located, declares
that this matter may be and is dismissed voluntarily on this 3rd
day of June, 1996, without prejudice and without costs.
~L~~-
Thomas N. Ganiaris
Attorney for Plaintiff
, ,
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