The enclosed WCB Form(s) (C8.1b) and/or (C8.4) have been filed …

James Keating

P.O. BOX 34 REMSENBURG, NY 11960

The enclosed WCB Form(s) (C8.1b) and/or (C8.4) have been filed with the NYS WCB for adjudication. By law, the Carrier is required to send you a copy. You are NOT responsible for any disputed amounts. Please note: Treatment is NOT being denied. The Carrier's objection to payment is based on the provider not following the WCB MTG recommendations.

PLEASE SCAN ALL PAGES OF THIS ATTACHMENT TOGETHER: C8.1, BILL AND CID 192709

Suffolk County Risk Management

C-8.1

NOTICE OF TREATMENT ISSUE(S)/DISPUTED BILL ISSUE(S)

CHECK TYPE OF CASE: WORKERS' COMPENSATION

VOLUNTEER FIREFIGHTER

ANSWER ALL QUESTIONS FULLY

ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS

VOLUNTEER AMBULANCE WORKER

1. W.C.B Case Number

2. Carrier Case Number

3. Carrier Code

4. Date of Injury

5. Social Security Number

G1078858

15W00292

W867501

02/25/2015

067627120

Name

Address to which notices should be sent

Apt. No.

6. Claimant

James Keating

P.O. BOX 34, REMSENBURG, NY 11960

7. Employer

Suffolk County Police Dept

30 Yaphank Avenue, Yaphank, NY 11980

8. Carrier

Suffolk County Risk Management

PO Box 6100, Hauppauge, NY 11788

9. Claimant's Doctor

Fiscina Peter

All Star Physical Therapy, 16 Memorial Blvd., East Moriches, NY 11940

*In volunteer firefighters' and volunteer ambulance workers' benefit cases, the liable political subdivision (or unaffiliated ambulance service as defined in Sec. 30 VAWBL) is

deemed to be the "EMPLOYER."

PART A NOTICE OF OBJECTION REGARDING FURTHER OR FUTURE TREATMENT (Notice must be filed within 5 days of denial/termination/withdrawal)

The carrier:

PART B NOTICE OF OBJECTION TO PAYMENT OF A BILL

FOR TREATMENT PROVIDED (Notice must be properly completed and filed within 45 days of submission of bill. Failure to pay undisputed portion of bill may subject carrier to interest on that portion).

Denies authorization of

, costing

more than $1,000 or requiring authorization under the Medical Treatment

Guidelines, requested by Dr.

on

based upon the conflicting medical report* of

Dr.

dated

.

Withdraws authorization for

granted on

to Dr.

upon conflicting medical report* of Dr.

based .

Bill pertains to treatment: in New York State

out of New York State dental

Date of C-4/Bill 08/10/2016 WCB Document ID# of C-4/Bill (Note: If C-4/Bill is not in the Board's file, it must be submitted with this form.)

Date of Treatment 03/04/16-03/30/16 Amont of Bill $ 1621.6

Amount in Dispute $ 1297.28

The carrier raises the following legal objections to the above cited bill for treatment rendered:

Claim has been controverted by Form C-7 dated

and

liability has not been resolved.

Terminates further medical treatment after

base upon conflicting medical report* of Dr.

dated

.

Objects to further treatment because failed to attend a scheduled IME

examination on

.

Prior authorization was not granted for treatment over $1,000. Request for treatment has been denied, withdrawn, or refused. Treatment Provided was not causally related to the compensable injury. Treatment provided within 30 days of initial treatment was outside of preferred provider organization (PPO). Medical Report for treatment was not timely filed or is legally defective.

Denies authorization of as the medical appliance or program is not covered under the WCL.

Medical appliance or program is not covered under the WCL. Provider is not authorized under the Workers' Compensation Law. Bill is not for treatment but for an evidentiary opinion.

Raises the Medical Necessity of the special medical service of

costing more than $1,000 requested

by Dr.

on

based

upon conflicting medical report* of Dr.

dated

in that the claim was controverted by Form C-7

dated

and compensability has not been established.

Requested treatment is not for an established site or condition.

Amount of bill for dental treatment or treatment outside of NYS exceeds community standard.

Diagnostic test was performed outside of network.

Other (Specify):

Compliance with Medical Treatment Guidelines: (ONLY applies to Knee, Shoulder, Neck and Mid and Low Back)

Treatment provided was not based on correct application of the Guidelines.

Explain Reason(s):

Treatment deviates from the Guidelines without securing a Variance. Treatment not consistent with the approved Variance.

Variance denied without claimant timely requesting review or variance denied by Board Decision filed:

Explain Reason(s)/MTG Reference:

VAR EXCEEDED&RES OF ORDER CHAIR,MG2 3/24/16 DENIED

*Conflicting Medical Opinion: The medical report constituting the conflicting medical opinion required for Part A must be filed simultaneously. If the

report has been previously filed with the Board, identify the WCB Document ID No.: 263374646

and date received by the Board:

Note: Raising the issue of liability under WCL Sec. 25-a is not a valid reason for terminating medical treatment, denying authorization for a special service, or denying payment of a bill for treatment. WCL Sec. 13(a) states that "the providing of medical treatment and care...shall not constitute the payment of compensation under section 25-a of this chapter." Carrier is to pay for all causally related medical treatment and file for appropriate relief with Special Funds, if applicable.

IT IS HEREWITH CERTIFIED THAT A COPY OF THIS FORM WAS SENT THIS DATE TO THE HEALTH PROVIDER.

Dated: 09/07/2016

Prepared By: Jessica Caruso

Tel No. & Ext.: 631-853-4954

Official Title: Workers' Compensation Examiner

Prescribed by Chair

C-8.1.0 (1-11) Workers' Compensation Board State of New York

REVERSE SIDE THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.

SEE REVERSE SIDE

Keating, James; DoA: 02/25/2015; WCB: G1078858

Suffolk County Risk Management

PO Box 6100 Hauppauge, NY 11788

CMC

All Star Physical Therapy

Peter Fiscina, PT 16 Memorial Blvd.

East Moriches, NY 11940

Date of Letter: 08/31/2016 Date of Invoice: 08/10/2016 Date Invoice Rec'd: 08/22/2016 Provider Federal TIN: 010885087 Point of Service: 11940

Regarding - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Patient Name: Keating, James

CC#: 15W00292

Date of Injury: 02/25/2015

WCB#: G1078858

Code Description

S43.402D Unspecified sprain of left shoulder joint, subs encntr S63.502D Unspecified sprain of left wrist, subsequent encounter

D/O/S

CPT Bill

03/02/2016 97014

03/02/2016 97035

03/02/2016 97110

03/02/2016 97140

03/04/2016 97014

Unit 1 1 2 2 1

Billed

CPT Allow

$20.48 97014

$15.40 97035

$61.14 97110

$65.14 97140

$20.48 0

Unit 1 1 2 2 0

03/04/2016 97035

1

$15.40 0

0

03/04/2016 97110

2

$61.14 0

0

03/04/2016 97140

2

$65.14 0

0

03/07/2016 97014

1

$20.48 97014

1

03/07/2016 97035

1

$15.40 97035

1

03/07/2016 97110

2

$61.14 97110

2

03/07/2016 97140

2

$65.14 97140

2

03/09/2016 97014

1

$20.48 0

0

03/09/2016 97035

1

$15.40 0

0

03/09/2016 97110

2

$61.14 0

0

Allowed $14.96 $12.22 $17.82 $0.00 $0.00

$0.00

$0.00

$0.00

$14.96 $12.22 $17.82

$0.00 $0.00

$0.00

$0.00

Prv. Paid

Obj/Note

$0.00 MC

$0.00 MC

$0.00 12d, MC

$0.00 12d

$0.00 1e, 13, C8.115

$0.00 1e, 13, C8.115

$0.00 1e, 13, C8.115

$0.00 1e, 13, C8.115

$0.00 MC

$0.00 MC

$0.00 12d, MC

$0.00 12d

$0.00 1e, 13, C8.113, C8.114

$0.00 1e, 13, C8.113, C8.114

$0.00 1e, 13, C8.113, C8.114

Claim Id: 192709 CE: Jessica Caruso Page 1

Keating, James; DoA: 02/25/2015; WCB: G1078858

Suffolk County Risk Management

PO Box 6100 Hauppauge, NY 11788

D/O/S

CPT Bill Unit

03/09/2016 97140

2

03/16/2016 97014

1

03/16/2016 97035

1

03/16/2016 97110

2

03/16/2016 97140

2

03/21/2016 97014

1

03/21/2016 97035

1

03/21/2016 97110

2

03/21/2016 97140

2

03/23/2016 97014

1

03/23/2016 97035

1

03/23/2016 97110

2

03/23/2016 97140

2

03/25/2016 97014

1

03/25/2016 97035

1

03/25/2016 97110

2

03/25/2016 97140

2

Billed

CPT Allow Unit

$65.14 0

0

$20.48 0

0

$15.40 0

0

$61.14 0

0

$65.14 0

0

$20.48 0

0

$15.40 0

0

$61.14 0

0

$65.14 0

0

$20.48 0

0

$15.40 0

0

$61.14 0

0

$65.14 0

0

$20.48 0-0

0

$15.40 0

0

$61.14 0

0

$65.14 0

0

Allowed $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

CMC

Prv. Paid

Obj/Note

$0.00 1e, 13, C8.113, C8.114

$0.00 1e, 13, C8.113, C8.114

$0.00 1e, 13, C8.113, C8.114

$0.00 1e, 13, C8.113, C8.114

$0.00 1e, 13, C8.113, C8.114

$0.00 1e, 13, C8.113, C8.114

$0.00 1e, 13, C8.113, C8.114

$0.00 1e, 13, C8.113, C8.114

$0.00 1e, 13, C8.113, C8.114

$0.00 1e, 13, C8.113, C8.114

$0.00 1e, 13, C8.113, C8.114

$0.00 1e, 13, C8.113, C8.114

$0.00 1e, 13, C8.113, C8.114

$0.00 1e, 13, C8.116

$0.00 1e, 13, C8.116

$0.00 1e, 13, C8.116

$0.00 1e, 13, C8.116

Claim Id: 192709 CE: Jessica Caruso Page 2

Keating, James; DoA: 02/25/2015; WCB: G1078858

Suffolk County Risk Management

PO Box 6100 Hauppauge, NY 11788

CMC

D/O/S

CPT Bill Unit

03/28/2016 97014

1

03/28/2016 97035

1

03/28/2016 97110

2

03/28/2016 97140

2

03/30/2016 97014

1

03/30/2016 97035

1

03/30/2016 97110

2

03/30/2016 97140

2

Billed

CPT Allow Unit

$20.48 0

0

$15.40 0

0

$61.14 0

0

$65.14 0

0

$20.48 0

0

$15.40 0

0

$61.14 0

0

$65.14 0

0

Allowed $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Prv. Paid

Obj/Note

$0.00 1e, 13, C8.116

$0.00 1e, 13, C8.116

$0.00 1e, 13, C8.116

$0.00 1e, 13, C8.116

$0.00 1e, 13, C8.116

$0.00 1e, 13, C8.116

$0.00 1e, 13, C8.116

$0.00 1e, 13, C8.116

Obj/Note 12d 13 1e

C8.113 C8.114 C8.115 C8.116

MC

Description

Maximum daily allowance applies ? PM & R Ground Rule # 11 and Chiro PM Ground Rule # 3 (12.01.2010).

Please see note in comment box below:

Treatment Authorization was: exceeded, denied OR never requested by Provider prior to rendering treatment.

Treatment was not based on correct application of Medical Treatment Guidelines. C8.1 will be filed or has been previously filed for this issue. PAYMENT DENIED.

Treatment deviates from the Guidelines without securing a Variance. C8.1 will be filed or has been previously filed for this issue. PAYMENT DENIED.

Treatment not consistent with the approved Variance. C8.1 will be filed or has been previously filed for this issue. PAYMENT DENIED.

C8.1 Filed: Variance denied without claimant timely requesting review, OR Variance denied by Board decision. Payment Denied.

The fee for this line has been discounted per the contracted rates with MagnaCare PPO. Questions regarding the discounted rates should be directed to 877-624-6209 YOU MUST USE OPTION 3 to reach the proper department.

Comments: 1) The variance granted was for physical therapy 2x a week for 4 weeks to the left shoulder. Date of service 3/4/16 represents the third visit in a weeks time. Treatment rendered was not to the variance. Therefore, payment is denied for this date.

2) Dates of service 3/9/16-3/23/16 are denied due to a variance not being secured.

3) Dates of service 3/24/16-3/30/16 are denied per Rescission Of The Order Of Chair filed 4/19/16 which stated, "The variance requested in the MG2 filed on 3/24/16 is denied."

Claim Id: 192709 CE: Jessica Caruso Page 3

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