i 

i Atrium Health

Joshua Bates

Account:--

June 28. 2019 

This is an itemization of the healthcare services for:

 

Patiem: Estes, Joshua Ad it Date: 07/09/18
Discharge Date: 07/10/18

Location: Carolina: Medical Center i

VI It Coverages: i

         

 

 

   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTINENTAL BENEFITS
Current Account Balance: $28,155,55
Ho mi a"
5V5 DI Code Descrip on NBC Gly Amount
ANESTHESIAGENERAL - - V, . 4 
01/101" 0370 HC ANESTHESIA TECHNICAL FEE PER LIMIT 1! $5365.65
- 
"352 NC CT ABDOMEN PELVIS WI CONTRAST (CT) 1 $4,315 10
EKGIECG IELECTRDOARDIOGRAMHBENERAL 
nuns/Ia NC ELECTROCARDIOGRAM 1] SIOIMO
EMERGENCY ROOM-GENERAL i 
0050 HC ED VISIT LEVEL 5 1 $1,960.0260 IV INFUSION CONCURRENT 1 $60.20
fl7/flil1l "25" NC IV UP TO 1 HOUR I 3115,65
LABORATORY PATHOLOGY GENERAL 
fl7l1fll15 "512 NC GROSS MICRO LEVEL (HIST) I 1 533750
iummronmsumL . - 
07/03"! 0301 "9 BASIC METABOLIC PANEL 1 $272.5"
"7/0915 0501 HC POC TROPONIN I (PM) 1 
07mm: 0305 HC CED AUTO WIAUTO DIF 1 5103.8"
01I03118 03fl7 HC URINALVSIS AUTO WIO SCOPE 1 $601!

 

 

RGICAL SUPPLIES AND DEVICESQENERAI: 
om um? 0271 He MANIFOLD 4 PORT slan NEPYUNE ssms'

07/10/18 0271 HC ADHESIVE DERMABOND LXE I smou
0271 HI: APPLIER CLIP LIGAMAX SMM 36mm

 

 

 

 

 

 

 

 

 

 

II you have any quesu'ons, please call (704)5124171
Si uu no puedo leer ei comemdo de esta en Ingles, por Iavnr ilamenos aI (704)512-7171' upcion #2 Espanol.

Page 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cod DeSc mun NDC Qty Amoum
01110110 0272 11c LINEAR 45 1 51,050.50
111110110 0212 NC ENDOFATH 45 2.5 (TRASW) 1 $555.20
111110110 0272 no LJWIRE 0100 1 5100.50
01110110 0212 Ho 45 Gsnsa 1 $505.70
01110110 0212 Hc RELOAD ECHELON as EST455 1 1 5505,70
07110115 0212 11c RETRIEVAL SYSTEM 50001 1 $100.00
01110110 0212 no SCISSORS A TIP 1 $151.20
07110110 0272 H1: SLEEVE TROCAR SM )1 15111111 1 5100.50
07110115 0212 Ho 12MM XCEL B12LT 1 000.00
OPERATING ROOM SEMES-GENERAL . 
07110110 0350 He SURGERV LEVEL 3 EA ADL 15 MINUTES 1 5 57.55500
07110110 0:150 HC SURGERY LEVEL 0 FIRST 30 MINUTES 1 57,020,111
or souRcE DRUG 
01100115 0535 HC 100ML 00701120005 0 $00.10
07100110 0010 HC FENTANVL CITRATE AMP 00400900422 1 $25.00
07010110 0530 Ho PROPOFDL 2110MB INJECTION 03323025920 40 5111.00
07110110 0535 11c 40M1510.4ML SYRINGE 00015052040 1 520.011
01110110 0533 Ho INJ 503111090302 1 $25.00
01110110 0535 Ho ONDANSETRON rm 5 MG INJECTION 0040017550: A 545.00
PHARMACY-GENERAL 1 . .
011011110 0250 Ho 50001113 INJECTION 00330105540 1 $45.00
07100110 0251 I11: 2-1.1 MPF 53322020005 1 32000
07100110 0251 H1: BR 10MGIML 5ML INJ 101457022005 1 $20.00
07100110 0251 H1: 10011113 SYRINGE 100400052902 1 342.501
071001111 0265 HC cT CONTRAST Iso 370 PER ML 1 120 $55.40
07010110 0250 NC IBUPROFEN 000Me TABLET 01130050410 1 5300
07110110 0251 H1: ANES GLYCOPVRROLATE 50314000105 1 $02.50
07110110 0251 H1: ANES SML 50011000205 10 302.50
07110111 0251 11c EUPIVACAINE 1-200000 VL 00400001511 1 $20.00
07110110 0255 Ho 05 112115 zoMEo 1000ML 00254103500 10 $107.05
07110110 0250 He CAPSULE 15114020000 1 53.00
07110110 0250 H1: AMOXICILLIN sooMG 10114020003 1 $3.00
07110110 0259 Ho TAE 00405012352 1 55.00
RADIOLOGY-DIAGNOSTICGENERAL -
07100115 0324 NC 0x CHEST 2 VIEWS (RD) 1 3347.501
RECOVERY RAL . 1
01110110 0710 11c RECOVERY PER mm" 45 5953.70
SERVICES- ENERAL
07100110 0752 Ho DES PER MINUTE 10 5154.00
01110110 0752 Ho 0135 PER MINUTE 152 
07110110 0762 H0 053 PER MINUTE 541 511190-10
10151 Charges 541,211.15

 

 

 

 

 

 



Descripuon

 

 

 

10(12/13 Comma al Payment $5,514.56
Colnluunca: 357

10123110 .5010

05/27"? PATIENT PAVMENT 65.57154

Total Faiient Pymems and Adj Stmenu -$4.111.54

Amount

 

 

lfyou have any quesm'nns. please call (704)512-7171

Si Ud no puedo leer el oomemdo de eSta en IngIes, par favor Ilamenos al (704)5124111. opCIon :12 EspanoI

Page 2



3 Conunenla' Benems

p0 Box 3510 EXPLANATION OF BENEFITS

Brandon FL 3350549610
ustomer Sewlce

Iv you have quesuons regardmg <<115 cVaim,
please wsil Us (Wine

orcau us a! (855) 28978471.

Forwarding Service Requested

 

 

 

Group Name: Diversanl, LLC

 

 

THIS Is NOT A BILL 

 
 

Paxiem; Jashuz Bales
Due: .Mys. 2m

  
          
   

cum Flnanzed Dah' 1010mm
Provide . CARDLINAS MEDICAL 

Rmdumg Provider. CARDLINAS (:94an
. 

Pauem 

 

 

 

 

 

 

 

 

 

 

 

   

 

 

 

 

Sm: mam" halges pm. Home Nu. We mm." may em mu mm 
mm
07/10/2018 Ememency Ream 224 so 59,528 as 323295 55357 31 50% AMP
07/09
(mm/2m Emergency Room 52 on 25 52.527 52937 25 100%
Tota' sum 75 same 323295 55 so on so on 53.971 54 53344 ss
Omev \nsurance/Mluslmem so on
Amoum Pa! 55,544 56
Amuum Pal May owe Provide 571 4
Nut 0 ockel pam- 5 sum:
Veav we mm pauem We." Mum om Moo; Rm "9
NETWORK Year to Summary so no no 5635:: no mzso on so no
Vear to Summary $28,295 as so on so on UNUMITED uwwao

 

 

 

 

 

'Moow OutaV'FuckeflurFaueM' vanemespunsmm ave flescnbad yam honklel flags mm mm 

REMARKS
AMP A Medical am re

 

wwas camp'eled and \dermfied nun-covered semoes

216 Le Ct
Concern NC 280252554
PARAGON Hours of Operatton 8AM 5PM EST
Omme com
Free 1-8007230'5392

August" 2019

Paragon Revenue Group IS a DEA
0! Jon Barry 5 Assocrates' Inc

FINAL NOTICE

"us \5 OUV Mat attempt to get you to pay you debt Pay the batance owed or contact our office at 119004306892

 

 

 

 

 

   

 

 

$18 135 65

 

 

 

 

$28 255 65

 

 

   
       

PAYMENT 

 

 

 

PO BOX 427
Concord. NC 29026

 

 

 

 

 

 

 

 

:mL Ht

 

 

 

"-11va

 

 

 

-- --
as PARAGON REVENUE GROUP

PO BOX 127
CONCORD NC 28026-0'27

January 16, 2020

Attn: Accounts Receivabie
Provider Name, Carolinas Medicai Center/Paragon Revenue Group

FORMAL NoncE RE: DISPUTE OF BILLED CHARGES

Insured Name, wJosnua Bates Account 
Patient Name: V'Jostlua Bates Claim No:

Date ol Service. owes/13.0711 0/13 Disputed Amount: 28,155.65

Claim Total Billed Amount: 541211.75 Claim Total Paid Amount: $13,055.10

Accounts Receivahie.
I am in receipt 0! your hlliing statement for the above reierenced dates of service.
This letter is formal notice that the amounts identified above are in dispute.

Please accept tnis document as written permission to discuss ttie apove account with Advanced Medical
Priong Solutions and the law retained by tnem on my oenallwnicn wlil be identified via
separate correspondence, Please also accept this dooiment as written permission to tne release oi my
Protected Healtn lnlonnation. as permitted by o1tne privacy regulation issued pursuant
to tne Health insurance Portability and Accountability Act to AMPS and the law retained on my
penall.

Tnis letter islonnal notice tnat i am disputing the accuracy and validity o1ttie Disputed cnarges under tne
lederal Fair Credit Billing Act and otner applicable lederal and state laws regarding, witnout
limitation, consumer protection. lair billing and collection practices, unlair and deceptive trade practices.
accord and satislaction and implied covenants olgood laitn, lairdealing and reasonaoility (collectively
"Applicahie Law'). i am requesting tnat this matter be investigated. tnat the Bill be appropriately adjusted,
tnat any finance and other lees related to ttie disputed amount be credited to my account. tnat i receive a
revised pilling statement as soon as possible. Until tnis matter is addressed and resolved in accordance
with Applicable Law. no payments will be made on the Disputed cnarges.

Pursuant to the FCBA. the Hospital is required to acknowiedge this notice oldispute within 30 days and.
within 90 days. must investigate tne Disputed Charges and eitner adjust the charges on ttie account and
send a corrected Bill or provide a written explanation ofwhy ttie ctiarges at issue are appropriately
included in ttie Bill. Unless ttie Hospital appropriately lollow the required procedures. Applicable Law
prohibits any legal or ottier action to collect tne disputed amounts or related charges, in addition,
protections and procedures under ottier Applicable Lawmust also be lollowed.

it you have any additional questions, please contact AMPS at (300) 309-0513.

Sincerely

Signature:

Date: - -