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HomeMy WebLinkAbout11-27-06 ~. ..,....-_..;o;v,....~=":- --..~+-~.~... .-:'.:~~--..~"'Ilo.h ........'~.-__..~-.- _0'__ ~'__~. _ _:_~":-.:~:::~:;:.=_~!:.;:.fM~~C~~~: ~ . , ,.- ~.''''''.o. .'. .c.~ _ :_ " '''+_' ..' .... - . ~-' STATE OF.~,n~n' a . .._ ._,C, InRe: C\,'o-\a-) Wo'o.\leJ("' Intbc Cu~r\arrl ~~."<~~- . ~ 'I ~ \ - ("')5 - d'\4.. l~'\ & (,01 \) S \ \ \ ('&.A),..~Q -:al'Ore.., C^r\l~~ PA l\O\"'b STATEMENT OF CLAIM I I 1. Select Medical CorporationIBureau of Account Management hereby presents for tiling against the above estate this statement of claim in the amount ofS.JOO.O<). 2. The basis for the claim is Select Medical Corporation Account # J I ~44 for date ofservice~5 3. The tax identification number of the claimant is 23-2892355. o S=O 4. The name and address of the claimant is: Select Medical Corporation 3607 Rosem~~o Avenue Suite 502 Camp Hill~ PA 17011. ~~93 '..Y"" ~ - 0 ----'00 '-_ ~ -on OC: . TJ ~o =-1 ..l> 5. This claim is Dot contimzent. - - 6. This claim i!.!!!!! secured. I under penalties of perjury, I declare that I have read the foregoing. and the facts alleged are true. to the best of my knowledge and belief. Executed this..J l day of N~em~ .20,QW 7/7' 2/lf'300$ Bureau, of Account Management Claimant . State ofPennsvlvania. County of Cumberland . " . IN WITNESS WHEREOF. I have set my hand and notarial seal this I \ day of /J()vem~ .20~ ~~Ii~ My CommisionExpires:.1ipo1J:' ~aJt '" 1 ,..,." = = <::n 2: o -: N -s -., -".cc-"" -' ,. I [--) n"1 - .. <Xl SSH CAMP HI PO BOX 642' PITTSBURGH 15264-2369 12 PATIENT NAME PA 5 FED. TAX NO. 17-972-1100 WOLAVER CLINTON L 160 CEDAR STREET MOUNT HOLLY SPRINGPA PHONE (717) 486-7443 LABORATORY GENERAL 'r~t_~f>:o ;Ii ;. 63 TREATMENT AUTHORIZATION CODES 66 EMPLOYER LOCATION A B" C b CAPITAL BLUE CROSS PO BOX 779503 ELECTRONICALL BILLED c d UB~OC8'I'~ATE :"""!~fj'\i~ 4 7 OCAlORIGINAL SSH CAMP HILL PO BOX 642369 PITTSBURGH PA 15264-2369 717-972-1100 251885943 090905 101105 32 WOLAVER CLINTON L 160 CEDAR STREET 03231925 M M 090905 11 3 4 14 51 000001612 WOLAVER'CLINTON L 160 CEDAR STREET MOUNT HOLLY SPRINGPA 17065 PHONE (717) 486-7443 01 90000 0120 ROOM & BOARD 923.00 0250 PHARMACY GENERAL 0258 PHARMACY IV SOLUTIONS 0259 OTHER PHARMACY 0270 MED/SUR SUPPLIES GENERAL 0361 MINOR SURGERY 0391 BLOOD ADMINISTRATION 0410 RESPIRATORY SERVICES GENE 0942 EDUCATION/TRAINING/DIETAR 32 881 103 1 2501 2 3 1670 15 0001 TOTAL CHARGE MEDICARE PART B ONLY CAPITAL BLUE CROSS 392039 Y Y Y Y WOLAVER CLINTON L WOLAVER CLINTON L 18 201166206M 18 R03079486 2005072674 5 5 476 0011244-02 111 MOUNT HOLLY SPRINGPA 17065 2953600 2001836 888000 1300 1072412 150000 82401 3643500 29400 10822449 FEP 104 518.5 V46.11 998.59 038.9 995.92 584.9 E878.6 996.74 453.8 518.5 475 9 96.72 090905 96.6 090905 34.91 092105 851832 BURICK THERESA 99.04 091005 99.04 091705 38.93 092605 G51832 BURICK THERESA CAPITAL BLUE CROSS PO BOX 779503 ELECTRONICALLY BILLED HARRISBURG PA 17177-9503 POST DATE: 12/31/05 476 * REPRINT * ------------------------------------------------------------------------------- 392039 Medicare National Standard Intermediary Remittance Advice FPE: 01/31/2006 PAID: 02/16/2006 CLM': 101 '!'OB: 121 .________=s._.______=____________________===____..=_=====__...______=__===._.___ PATIENT: WOLAVER HIC: 201166206M PAT STAT: CLAIM STAT: 1 CLINTON L SVC FROM: 09/09/2005 THRU: 10/11/2005 PCN: 001124402 MRN: 000001612 ICN: 20603103399802 01 _=_=_____===_===_=___.__=_====m===....__==__=_=____=__=======________.__.__===_. CHARGES: 36659.51=REPORTED 2301.4Z=NCVD/OENIED O.OO-cLAIM ADJS 34358.09-COVERED DAYS/V:IS:ITS: O-COST RElPT 32=COVD/UTIL O-NON-COVEREO O-COVD VISITS O-NCOV VISITS REMARK CODES: REV 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 0300 J)l'!'E 09/16 09/18 09/24 09/11 09/13 09/14 09/19 09/28 10/02 10/03 10/07 09/10 09/21 09/11 09/16 09/17 09/18 09/24 09/18 09/16 09/19 09/16 09/19 09119 09/29 09/21 09110 09/11 09/12 09/13 09/14 09/16 09/17 BCPCS 36415 36415 36415 36415 80048 B004B 80048 B0048 80048 80048 80048 B0048 80048 B0053 80053 80053 80053 80053 80202 81002 81002 81015 81015 82270 82565 82947 B3735 83735 83735 83735 83735 83735 83735 .\PC/HIPPS !<<)DS 91 59 91 PAYMENT DATA: =DRG O.OO=DRG AMOUNT O.OOmDRG/OPER/CAP 28571.14-LINE ADJ AMT O.OO=OUTLIER O.OO=CAP OUTLIER O.OO=CASH DEDUCT O.OO=BLOOD DEDUCT 1860.80=COINSURANCE O.OO=PAT REFUND O.OO=MSP LIAS MET MAOl an 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 o o o 1 1 1 1 1 1 1 1 1 CIUlGES 15.'73 15.'73 15.73 31.46 68.97 68.97 68.97 6B.97 6B.97 68.97 68.97 68.97 68.97 105.27 105.27 105. Z7 105.27 105.27 124.63 19.36 19.36 21. 78 21. 78 25.41 39.93 54.45 67.76 67.76 67.76 67.76 67.76 67.76 67.76 .w.OWREIK GC 3.00 co 3.00 CO 3.00 CO 6.00 CO 7.77 CO 11.83 CO 11.83 co 11.83 CO 11.83 co 11.B3 co 11.83 CO 7.77 CO 11.83 CO 10.19 CO 10.19 CO 10.19 CO 14.77 CO 14.77 CO 18.93 CO 3.57 CO 3.57 CO 0.00 co 0.00 co 0.00 CO 4.11 co 3.76 CO 9.36 CO 9.36 CO 9.36 CO 9.36 CO 9.36 CO 9.36 CO 9.36 CO RSll 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 B15 815 151 42 42 42 42 42 42 42 42 42 O.200-RSIM RATE O.OO=MSP PRIM PAYER O.OO-PROF COMPONENT O.OO-ESRD AMOUNT 1556.76=PROC CD AMOUNT 3926. 15-ALLOW/REIM O.OOcG/R }\MOUNT O.OO-INTEREST O.OO-CONTRACT AOJ 0.20-PER DIEM ~ 3926.15=NElT REIM ~ .ul)t!N'r 12.73 12.73 12.73 25.46 61.20 57.14 57.14 57.14 57.14 57.14 57.14 61.20 57.14 95.08 95.08 95.08 90.50 90.50 105.70 15.79 15.79 21. 78 21.'78 25.41 35.82 50.69 58.40 58.40 58.40 56.40 5B.40 58.40 58.40 REIIARl COIlES 0300 10/03 83735 1 67.76 9.36 co 42 58.40 0300 10/05 83735 1 &7.76 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09/23 85014 1 18.15 3.31 CO 42 14.84 0300 09/25 65014 1 18.15 3.31 co 42 14.84 0300 09/27 8S014 1 18.15 3.31 CO 42 14.84 0300 09/13 85014 91 2 36.30 6.62 CO 42 29.68 0300 09/14 85014 91 2 36.30 6.62 CO 42 29.68 0300 09/15 85014 91 2 36.30 6.62 co 42 29.68 0300 09/17 85014 91 2 36.30 6.62 CO 42 29.68 0300 09/11 85018 0 18.15 0.00 co B15 18.15 0300 09/12 85018 1 18.15 3.31 CO 42 14.84 0300 09/16 85018 0 18.15 0.00 CO 815 18.15 0300 09/18 85018 0 18.15 0.00 CO 815 18.15 0300 09/19 85018 0 18.15 0.00 CO 815 18.15 0300 09/20 85018 1 18.15 3.31 CO 42 14.84 0300 09/22 85018 1 18.15 3.31 CO 42 14.84 0300 09/23 85018 1 18.15 3.31 CO 42 14.84 0300 09/25 85018 1 18.15 3.31 CO 4Z 14.84 0300 09/27 85018 1 18.15 3.31 CO 42 14.84 0300 09/13 85018 91 2 36.30 6.62 CO 42 29.68 0300 09/14 85018 91 2 36.30 6.62 CO 42 29.68 0300 09/15 85018 91 2 36.30 6.62 CO 42 29.68 0300 09/17 85018 91 2 36.30 6.62 CO 42 29.68 0300 09/17 85025 1 71.39 10.86 CO 42 60.53 0300 09/19 85025 1 71.39 10.86 CO 42 60.53 0300 09/26 85025 1 71.39 10.86 CO 42 60.53 0300 09/29 85025 1 71.39 10.86 co 42 60.53 0300 09/30 85025 1 71.39 10.86 CO 42 60.53 0300 10/01 85025 1 71.39 10.86 CO 42 60.53 0300 10/02 85025 1 71.39 10.86 CO 42 60.53 0300 10/03 85025 1 71.39 10.86 CO 42 60.53 0300 10/04 85025 1 71.39 10.86 CO 42 60.53 0300 10/05 85025 1 71.39 10.86 CO 42 60.53 0300 10/06 85025 1 71.39 10.86 co 42 60.53 0300 10/07 85025 1 71.39 10.86 CO 42 60.53 0300 10/08 85025 1 71.39 10.86 CO 42 60.53 0300 10/09 85025 1 71.39 10.66 CO 42 60.53 0300 10/10 85025 1 71.39 10.86 co 42 60.53 0300 09/10 85027 1 61.71 9.04 CO 4Z 52.67 0300 09/11 85027 1 61.71 9.04 CO 4Z 52.67 0300 09/13 85027 1 61.71 9.04 CO 4Z 52.61 0300 09/16 85027 1 61.71 9.04 CO 4Z 52.67 0300 09/18 85027 1 61. 71 9.04 CO 42 52.61 0300 09/21 85027 1 61. 11 9.04 CO 42 52.67 0300 09/24 85027 1 61.71 9.04 CO 4Z 52.67 0300 09/28 85027 1 61.71 9.04 CO 42 52.67 0300 09/21 85576 1 160.93 30.01 CO 42 130.92 0300 09/12 85610 1 39.93 5.49 CO 4Z 34.44 0300 09/13 85610 1 39.93 5.49 co 42 34.44 0300 09/14 85610 1 39.93 5.49 CO 42 34.44 0300 09/15 85610 1 39.93 5.49 CO 42 34.44 0300 09/16 85610 1 39.93 5.49 CO 42 34.44 0300 09/17 85610 1 39.93 5.49 CO 42 34.44 0300 09/18 85610 1 39.93 5.49 CO 42 34.44 0300 09/19 85610 1 39.93 5.49 CO 42 34.44 0300 09/21 85610 1 39.93 5.49 CO 42 34.44 0300 09/11 85610 91 2 79.86 10.98 co 42 68.88 0300 09/21 85730 1 56.87 8.38 CO 42 48.49 0300 09/10 85730 91 3 170.61 25.14 co 42 145.47 0300 09/11 85730 91 3 170.61 25.14 CO 42 145.47 0300 09/10 86850 00345 1 88.33 10.28 CO 45 75.11 PR 2 2.94 0300 09/12 86850 00345 1 88.33 10.28 co 45 75.11 PR 2 2.94 0300 09/16 86850 00345 1 88.33 10.28 CO 45 75.11 PR 2 2.94 0300 09/10 86900 00409 1 22.99 4.84 co 45 16.02 fR 2 2.13 0300 09/12 86900 00409 1 22.99 4.84 CO 45 16.02 PR 2 2.13 0300 09/16 86900 00409 1 22.99 4.84 co 45 16.02 PR 2 2.13 0300 09/10 86901 00409 1 42.35 4.84 CO 45 35.38 PR 2 2.13 0300 09/12 86901 00409 1 42.35 4.84 CO 45 35.38 PR 2 2.13 0300 09/16 86901 00409 1 42.35 4.84 co 45 35.38 PR 2 2.13 0300 09/10 86920 00346 1 272.80 14.69 co 45 253.16 PR 2 4.95 0300 09/12 86920 00346 1 272 . 80 14.69 co 45 253.16 PR 2 4.95 0300 09116 86920 00346 1 272.80 14.69 CO 45 253.16 PR 2 4.95 0300 09/16 87040 91 4 798.60 57.68 co 42 740.92 0300 09/09 87070 1 165.77 12.03 co 42 153.74 0300 09/15 87070 1 165.77 12.03 CO 42 153.74 0300 09/16 87070 0 165.77 0.00 CO Bl5 165.77 0300 09/21 87070 1 165.77 12.03 CO 42 153.74 0300 09/22 87070 1 165.77 12.03 co 42 153.74 0300 09130 87070 1 165.77 12.03 CO 42 153.74 0300 09/16 87075 0 255.31 0.00 CO 815 255.31 0300 09/21 87075 1 255.31 13.22 CO 42 242.09 0300 09/16 87086 1 60.50 11.28 CO 42 49.22 0300 09/19 87086 1 60.50 11.28 CO 42 49.22 0300 09/12 87324 1 104.06 15.39 CO 42 88.67 0300 09/21 89051 1 81. 07 7.70 CO 42 73.37 0320 09/26 36569 00187 1 1566.95 168.82 CO 45 1355.93 PR 2 42.20 0320 09/16 71010 00260 1 324.28 23.19 CO 45 282.11 Pll 2 18.98 0320 09/19 71010 00260 1 324.28 23.19 co 45 282.11 Pll 2 IB.98 0320 09/21 71010 00260 1 324.28 23.19 CO 45 282.11 PIt 2 18.98 0320 09/30 71010 00260 1 324.2B 23.19 co 45 282.11 PIl 2 18.98 0320 10103 71010 00260 1 324.28 23.19 CO 45 282.11 Pll 2 18.98 0350 09/14 70450 00332 1 1514.92 102.16 co 45 1329.18 Pll 2 83.58 0350 09/20 7Zl93 00283 1 2060.63 143.05 CO 45 IBOO.54 Pi 2 117.04 0350 09/20 74160 00283 1 1990.45 143.05 co 45 1730.36 PIl 2 117.04 0402 09/26 76942 0 1420.S4 0.00 CO 815 1420.54 0420 09/12 97001 GP 1 136.00 58.43 co 42 62.96 PIl 2 14.61 0420 09/20 97110 GP 1 51.00 21. 63 CO 4Z 23.96 PIl 2 5.41 0420 09/29 97110 GP 1 51.00 21.63 CO 42 23.96 PIl 2 5.41 0420 09130 97110 GP 1 51.00 21.63 CO 42 23.96 Pll 2 5.41 0420 10/04 97110 GP 1 51.00 Zl.63 CO 42 23.96 PIl 2 5.41 0420 10/06 97110 GP 1 51.00 21.63 CO 42 23.96 PR 2 5.41 0430 09/12 97003 GO 1 136.00 62.29 CO 42 58.14 Pll 2 15.57 0430 09/14 97110 GO 1 51.00 21.63 CO 42 23.96 PR 2 5.41 0430 09/16 97110 GO 1 51.00 21.1i3 CO 42 23.96 PIl 2 5.41 0430 09/19 97110 GO 1 51. 00 21.63 CO 4Z 23.96 PR 2 5.41 0430 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