HomeMy WebLinkAbout04-01-13 STATE OF f LIML�(
In Re:
iiN - 12—IZ97 Un Case# 1 In the �UAti I(� CU
Estate of: - - . ( 0 Z
STATEMENT OF CLAIM
1. Select Medical Corporation/Bureau of Account Management hereby presents for
filing against the above estate this statement of claim in the amount of
$ USAF 3Z- .
2. The basis for the claig is Account# �j'70 for date of
service JJ4. Z,I - ,
c o M ;
3. The tax identification number of the claimant is 23-2892355. c �'
M _.�
4. The name and address of the claimant is: Bureau of Account Mana m9n 6&-' � C
Rosemont Avenue Suite 502 Camp Hill, PA 17011. Phone#717-21 m5?t ° c
5. This claim is not contingent. »"'
6. This claim is not secured. Co �
I under penalties of perjury, declare that I have read the foregoing, and the facts alleged
are true, to the best of my knowledge and belief.
Executed this 1 day of c 2013
An el Brop Phone# 717-214-3005 Bureau of Account Management Claimant
abrown @outtechinc.com
State of Pennsylvania, County of Cumberland +�
IN WITNESS WHEREOF, I have set my hand and notarial seal this _day of
M 2013
Notary Public
My Commision Expires: COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL
HEATHER E.SCHWEAR,Notary Public
Lower Allen Twp.,Cumberland County
My Commission Expires November 19,2016
SSH CAMP HILL SSH CAMP HILL 476 0013761-01
503 NORTH 21ST STREET PO BOX 642369 5375 0111
CAMP HILL PA 170112288PITTSBURGH PA 15264
717-972-1100 251885943 111612 112912
208244523T 5 ALLIANCE DRIVE
PTASZEK BARBARA E CARLISLE PA 17013
11171928 F 11161213 3 4 22 20
PTASZEK BARBARA E
5 ALLIANCE DRIVE O1 12850037 20039 00
APT 202 80 1300
CARLISLE PA 17013
0120 ROOM & BOARD 1285 . 00 13 1670500
0250 PHARMACY GENERAL 295 932900
0258 PHARMACY IV SOLUTIONS 126 207425
0259 OTHER PHARMACY 6 32100
0270 MED/SUR SUPPLIES GENERAL 1379 850845
0300 LABORATORY GENERAL 52 554276
0320 RADIOLOGY DIAGNOSTIC GENE 5 200795
0381 BLOOD PACKED RED CELLS 2 108432
0386 BLOOD-OTHER COMPONENTS 1 102414
0410 RESPIRATORY SERVICES GENE 496 2539350
0420 PHYSICAL THERAPY 2 14850
0430 OCCUPATIONAL THERAPY GENE 3 29810
0440 SPEECH PATHLOGOY GENERAL 2 45650
0731 HOLTER MONITOR 13 314600
0801 RENAL DIALYSIS 3 321228
0921 PERIPHERAL VASCULAR LAB 1 116952
0942 EDUCATION/TRAINING/DIETAR 7 15620
0001 1 1 120912 8057747
1346248333
MEDICARE NS 52280 Y Y 8057747 392039
PTASZEK BARBARA E 18 208244523T
518 . 81Y 507 . 0 Y 584 . 5 Y 262 N 038 . 9 Y 998 . 02Y 995 . 92Y 008 .45Y V55 . 1
9 V46 . 11 518 . 0 N 578 . 1 N 599 . 0 N 359 . 81N 560 . 1 N 041 . 7 N 490 N 414 . 01Y
518 . 81 207 E878 . 8 Y 207
1790786499 IGC30374
96 . 72 111612 96 . 6 111612 39 . 95 111912 COHEN HOWARD
1790786499 1GC30374
99 . 04 111812 99 . 15 112612 COHEN HOWARD
MEDICARE NS B3282E000OOX
PO BOX 890122
CAMP HILL PA 17089-0122
POST DATE: 12/09/12 476 0013761 Elec Billed * REPRINT
Page 2 of 2
-------------------------------------------------------------------------------
Medicare National Standard Intermediary Remittance Advice
SELECT SPECIALTY HOSPITAL - CEN FPE: 01/31/2013 NOVITAS SOLUTIONS
PO BOX 2034 PAID: 12/18/2012 MEDICARE A
MECHANICSBURG PA 170550793 CLM# : 47 CAMP HILL, PA 170890122
NPI: 1346248333 TOB: 111
PATIENT: PTASZEK BARBARA E PCN: 001376101
HIC: 208244523TA SVC FROM: 11/16/2012 MRN: 000005375
CLAIM STAT: 1 THRU: 11/29/2012 ICN: 21234600530707PAM
CHARGES: PAYMENT DATA: 207=DRG 0 . 000=REIM RATE
80577 . 47=REPORTED 26268.26=DRG AMOUNT 0. 00=MSP PRIM PAYER
0. 00=NCVD/DENIED 0.00=DRG/OPER/CAP 0.00=PROF COMPONENT
0.00=CLAIM ADJS 0.00=LINE ADJ AMT 0.00=ESR0 AMOUNT
80577.47=COVERED 0.00=OUTLIER 0.00=PROC CD AMOUNT
DAYS/VISITS: 0 0 80577 .48-ALLOW/REIM
13=COST REPT .00=CASH DEDUC
O=COVD/UTIL 1084 .32=BLOOD DEDUCT 0 . 00_INTEREST
O=NON—COVERED 0.00=COINSURANCE 54309.21=C0NTRACT ADJ
O=CCVD VISITS 0.00=PAT 0 . 00=PER DIEM AMT
O=NCOV VISITS 25183. 94=NET REIM AMT
ADJ REASON CODES: CO 45 54309. 21
PR 66 1084 .32
REMARK CODES: MA02
-------------------------------------------------------------------------------------------------------------
REV DATE HCPCS AFC/HIPPS MODS {QTY CHARGES ALLOW/REIM GC RSN AMOUNT REMARK CODES
LICN HCPI
SVC Desc
0731 11/29 13.000 3146.00 3146.00
0801 11/29 3.000 3212.28 3212.28
0921 11/29 1.000 1169.52 1169.52
0942 11/29 7.000 156.20 156.20
-------------------------------------------------------------------------------------------------------------