HomeMy WebLinkAbout04-01-13 STATE OF 510M I"/
In Re:
Case # 2j In thef k)
Estate of
STATEMENT OF CLAIM
1. Select Medical Corporation/Bureau of Account Management hereby presents forte m
filin a ainst the above estate this statement of claim in the amount of C> C>
$� rn sn mrn
rn
r m ;D v
2. The basis for he claim is Account# ���O7i for date of z �'- � (:>
°
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service /Z o
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3. The tax identification number of the claimant is 23-2892355. :� s Cn C>
4. The name and address of the claimant is: Bureau of Account Management 3607
Rosemont Avenue Suite 502 Camp Hill,PA 17011. Phone#717-214-3005.
5. This claim is not contingent.
6. This claim is not secured.
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 I I day of M n.r r. , 2013
AAv#_Browd Phone# 717-214-3005 Bureau of Account Management Claimant
abrown@outtechine.com
State of Pennsylvania, County of Cumberland 41,
IN WI�TnNESS WHEREOF, I have set my hand and notarial seal this _day of
/Vl0-rc 2013
Notary Public
My Commision Expires: 11 119 1 I (1 -MMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL
HEATHER E.SCHWEAR,Notary PubNo
L0W ANen 1Wp.,Cumberland Camry
My Cam*Wm E*=November 19,2018
SSH CAMP HILL SSH CAMP HILL 476 0013621-02
503 NORTH 21ST STREET PO BOX 642369 5256 0111
CAMP HILL PA 170112288PITTSBURGH PA 15264
717-972-1100 251885943 072512 080912
R12687004 2100 BENT CREEK DRIVE
SHOPE ARTHUR R MECHANICSBURG PA 17050
06231926 M 07251219 3 4 19 20
SHOPE ARTHUR R
2100 BENT CREEK DRIVE O1 12850080 1500
MECHANICSBURG PA 17050
PHONE (717) 795-1100
0120 ROOM & BOARD 1285 . 00 15 1927500
0250 PHARMACY GENERAL 286 818275
0258 PHARMACY IV SOLUTIONS 97 403625
0270 MED/SUR SUPPLIES GENERAL 916 629225
0410 RESPIRATORY SERVICES GENE 108 310200
0942 EDUCATION/TRAINING/DIETAR 5 11880
0001 1 1 082012 4100705
1346248333
MEDICARE NS PART B ONLY52280 Y Y 392039
CAPITAL BLUE CROSS 39T299 Y Y 39T299
SHOPE ARTHUR R 18 174200426M
SHOPE ARTHUR R 18 R12687004
120704649
486 Y 262 Y 518. 81N 569.81Y 998.59N 041. 12N 428. 0 Y V58 .75 401. 9 Y
9 244 . 9 Y 332 . 0 Y 707. 03Y 707.22Y 285 . 9 Y 275 .41Y 275.3 Y 780 .97N 787 .20N
486 193 E878 . 8 N 193
1790786499 1GC30374
COHEN HOWARD
CAPITAL BLUE CROSS B3282E000OOX
PO BOX 779503
HARRISBURG PA 17177-0000
POST DATE: 8/20/12 476 0013621 Elec Billed * REPRINT
i�f1ec�lcos�� xP1a��G��cs�, &I.)A-1Vs �,v PEA
1r�C.�,(- -5-.---------------------- �
--------------------------
-- ----------�- ------------
Medicare National SCandard Intermediary Remittance Advice
FFE: 01131/2013
PAID: 08/28/2012 I
CLM11 : 4
NPI: 1346248333 TOB: 110
.--__•....•---o Cii s:=>=•-----T�aaaasaam=axzaaaaaa-=v==--.-c.-.-.:..�=v=6cc;:�:�:-.••...-. •_.......____..__ -.,
PATIENT: SHOPE JR ARTHUR R PCN: 001362102
1110: 174200426M SVC FROM: 07/25/2012 MRN: 0000052.56
PAT STAT: CLAIM STAT: 4 THRU: 08/09/2012 ICN: 21223500061607PAM
CHARGES: PAYMENT DATA: 193=DRG 0.000=RLIM RATE
47. 05-•REPORTED 0.00=DRG AMOUNT 0.00=MSP PRIM PAYER
1007. 5=NCVD/DENIED 0.00=DRG/OPER/CAP 0.00=PROF COMPONENT
= 0.00-LINE ADJ AMT 0.00-ESRD AMOUNT
0.00-COVERED 0.00=OUTLIER 0.00=PROC CD AMOUNT
DAYS/VISITS: 0.00=CAP OUTLIER 0.00--ALLOW/REIM
ONCOST REPT 0.00=CASH DEDUCT 0.00=G/R AMOUNT
0=COVD/UTIL 0.00=BLOOD DEDUCT 0. 00=INTEREST
0=NON-COVKRFD 0.00=COINSURANCE O.UU=CONTRACT ADJ
O-COVD VTSTTS 0.00=PAT REFUND 0. 00=PF:11 DfEM AMT
O=NCOV VISITS 0.00=MSP LIAB MET 0. 00-NET REIM AMT
REMARK CODES: MA02
-------------------------------------------------------------------------------------------------------------
RP.V DATE HCPCS AFC/HIPPS MODS QTY CHARGES ALLOW/REIM GC RSN AMOUNT REMARK CODES
0120 08/09 0 19275.00 0.00 PR 31 19275.00
0250 08/09 0 8182.75 0.00 PR 31 8182.75
0258 08109 0 4036.25 0.00 PR 31 4036.25
0270 08/09 0 6292.25 0.00 PR 31 6292.25
0410 08/09 0 3102.00 0.00 PR 31 3102.00
0942 08/09 0 118.80 0.00 PR 31 118.80
-- ---_. _......--....-..-------------------------------------------------------------------------------------------
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