Camrfifil' Delailed Claim Summary - Prepared Feb 03. 2020 Medical Claim-- Aug 26. 2019 Fee Michelle Kuppersmilh Total Charge(s) Provider Charged: $2400 on :a'eFrrsi red Sep 10. 2019 Coverage Paid: CareFirsi Paid: eFrrsi amp ere; Sep 18. 2019 Pruvles' CLINICAL LABS $0 on You owe:. $2400 on $000 Denied Amounl: $2400Do 'rms balance rellecls [he emovm you may owe your provider, however will nor rellecl any payments you have or will make. Itemized Charge(s) Medical Care Aug 26. 2019 Serv :e n; Medical Care Provider Charged: $2400 00 Coverage Paid: CareFirsi Paid: Lev - 3ZA - Beneliis for (his service are available when rendered by lhis provider. The member is not liable for lhese charges. - 3RV - Beneliis for (his service are available when rendered by lhis provider. The member is liable for lhese charges. $0 You owe:. $2400 5000 Denied Amounl: $2400Do l'egc 01 5 (2121:1131 Delailed Claim Summary - Prepared Mar 02. 202a Medical Claim-- NOTE: This claim has been adjusred. ., Aug 26, 2019 Sep10,2019 LABS Page Not Available at this time Mar 02. 2020 Total Charge(s) Provider Charged: $7200 Coverage Paid: $3600 9" You Owe:' $0 0" AHowed Charge: $3600 CareFirsI Paid: $3600 9" 'rms Manse reflects the amount you may owe your provmer. however nor reflect any payments you have or make. Itemized Charge(s) Medical 2: Aug 26, 2019 Medical Provider Charged: $2400 Coverage Paid: $1200 a" You Owe:' $0m AHowed Charge: $1200 CareFirsl Paid: $1200 9" n, 9/25/2013 . 0 Mount Smal AUTHORIZ RTIONS AND ASSIGNMENTS 1. or PAYMENT [All Pa em? 7 ln all senlleexl assl nme al nenems anu eala lenaelea, aalee lnal 1 am lel any and all enalnes mm by Mom smal Hespllal {'Mmml 5mm") wan m: cl In sucn eelylees Ind care unless wnllam aelwean Mounl S'nal enu my lneulanee sanlpeny amylase ulnenulse and/m unless pleyluea law I1 lne eyenl lnal laqufllefl sawlees al'u aulnallzes by my campany 29's: la lal all Sch/lacs as names uean' un ess clhelwlse by law eelnanze paymP/lr ul mealcal uenenu la I am alre-lly Io Muunl Slnal le cayel Best el Cale ans renaeleu la or my oesenuenls us me nose-Isl Upon vetalpl al a uleunl slnal ll agree la lmmzalakely pay all amaunls nol Cavemfl by 'nsumnce unless by law ll any lnsulsnce lwa elects lny elalm or gays pan pl lne clalln I my be lal paymenl of any balanes as delammed ay Meunl slnal lmmEflraKfl'y won 0| Mn coyelage unless DmeMlsuleVlded by law 2. INFCE in ln me even- my new uenes pa menu In Mum! slnal semees renewed |n me naleny glue my consenl |u neya an neplaeenlallye a5 Maunl Slr'al aanlael my ana ls alaylne lo nly lnranne ln and uqcumenlahon lne semeas rammed m- by Mount anal nnlan nlay as lanenae ln mam Iur my MSWEY la leeyeluale am en lo ueny paymem lel sucn selylces nulhovl've Moun} slnal nly lleallng anyslelan and kn!" new We lo use ana ulsclase my nealln lnlolmamn In! all necessaly lleslrnen: asymenl ind naslln sale naalallms purposes el my nsalzn lnlannanan mzy lnlarnla-lan lslsung la nlenlsl enalul and lnel any sucn Walmallall nlay ae slselsaen llnelualng exammahvn ana ln E'lhlr nan: copy an 50mm] la lrsulels 1 mm Credll agenmes enu guavamurs solely a named for naylnenl al Maunl slnal enavges ana/al aleleselanal th'gu lna be slselaeeu la any creel: agency) OF a. ASSIGNMENT 0F BENEFITS Medl r6 anlv Pm A_and [in a welders I asnv'y ln. lnlannallan glvun me ln analylne lal paymenl vrdar 'an al lna Sacral nu ls sullen aulnanze ally nelsa. al was cal or 47mm me tn lulcas we Soual Sucwly 3rd Cams" Var Mlalcwr: and Mgulcmd Senses or lylrem'edlallzs av can av; any .nlannslen lnlannallan N'Blmg la manzal anulal neenuml lnla el a relalea Medm elaln Imus" lnal paymenl be mass on try bsnall benem. payable lo and'ur Muum slnal sawlcey bflhe anyslelan unsung lne 52mm TO NVS LAW nal um. a uncanny was, my eallh n'an usual; .la lnal a ls: alne an"s nun. yam: .les yen as 1 was. .l . are" unuelslalla ual and an al D'uwduls who lensel sewlces el Maunl slna may lee employed by or by Meunl slnal a: may he ~aeaenaenl Mu ale as emaloyes falling?! by Mom slnal mnnel unselelena lnel phyilclan/Wovmef: wna amylae seylaes Mann! slnal may ln ln sens hesm' alans as Mvum slnal eyan nrney are employau ay ny unselslena lnal energee lal anyslel 'omlesiloml aewas Dilemma el Mounl slnal at: lncluaea ln surges and lnel D'ly'm'dflfi'wuwdem nay bl" la: lnell 'pmlfislanll sanalalaly llanl Maunl slnal. Mn nlney ale employed by ur mmladzd by nlnunl slnel I undelslann lnal chem w.IIl lr'angl'lg lul fly eelylees la aslennlne the name ammo: name menlnq arc lelepnana nunlne>> el any alnsl elannaracllce wnasa le ca anangea by lne anu l-lnalnel lne senllces .yna ale unoloyes al by Mcunl lnal n: amuse sen/mes palnulagy "5an lat} elegy>> are Veasanm, be Drowned la me unuelslaru :nzl can aslemnc neall>> plans new: paleu ln by wl a aw empluyea uy Mount slnal uy lre 'Vlnu a mum loalaal 1 al ls ,7 . naylgallnamanyselans prams-m undelslinfl lnal ennlasl lnlannalloln val anyman elnlas :anlraclen uy Mowl slnal any; ls amylau selulaes al Meunl Slnal ls syallsule al Registration 9/25/2018 MICHELL . "1:3 Mount '53 Sinai 1 i for patients who have appomtmenis in one of Mount Sinai's provider based practices \chnjuuhuflu \m in i. \inmu pruniiwn!tli.m mum. mm m1 mm Incmu' my \m "mum Smumwrung, ("Nth-x um-mn-umu mm and'ur mm" - Human and rrinan 'mcn )me dogma wmmimm Know. "minnow or pnmuw. [w m} .mw rye um rum" A hmplui dam "mm m: min-a cimim 1m m- mm Hug app .m pmuh. mgnullca) m: \nu lmu- In: m, )uur umvmnu' \mva mm mm riurgcx mu dim-mu. Emmi "in-Mm hm Ihmugi) 3m" mm mm uminLk'uImNm ism. mu'rmi h) Mcdmirv ilvm rm, mm yau mun h, ,qu "win," Imuh plan mummumnu Mmimey: We "fly )our mummy) mam lh'sc chum>> "1mm hmed m1 Imun pm Snm: dppl) mm chmgu: acuucum Mum "hm mum- cnw: mun mu: uddilicnni qucflium aim "we mung" mi, kindly mun nun urnurpmnu "Hump-n In our uiuur praclicl' <urgw MN bind in Mcmuit Van - 1" physimn -\ml mu ('Iinirni "mm- hiliud In "Ed-cam mu \nll u. bumnmn \uilm mm: an: rm-Pm \lml "mm-m n: um mm wmum mwmqun my; "iiJurlu Um Inwrunm'wmwn} - Hm mm m- I'Miumcur (in nm- mum urHMHan' .mu \luiuun.zmm'mmu} lw wh'nm' qunimgmv "mm (W "my Hm .m ranmlcufuhm a ucmwc rm} n'xnm'ui'.' mm Is nu mumlm unmaum Irwu luwl \ccundm'y manuwur Irspunm Ililv < December 13. 2019 WELCOME TO GENOPTIX Michelle Ku elsmilh Dear Michelle Kuppersmith. Recently you had a procedure perfumed at Mt. sinai Medical Center. Myel At that time. your physician, Dr. Kremyarlskaya Marina collected a specimen and sent it to Genopllx Medical Laboratory iortesting and diagnosis. We are a nationally accredited laboratory which specializes in oncology testing. For more lrlformallon about our laboratory. please visit This letter will explain how we will work with you and your insurance company to quickly process your claim and maximize your insurance henetits, which can loweryour out-ot-pocket costs. Based on the insurance intormaticn you plovlded. Genoptlx is considered an Out-cf--Network provider. We are not contracted with all insurance providers but. to the maxlmum extent permitted by law. we will attempt to act as an ln-Netwolk provider. regardless of our status your insurance company. Your financial it any. Will be at an ln-Network coinsurance and/or deductible benefit plan level tor pathology laboratory services. Please note the followlng important Ilems' Due to our Out-oI-Network status with your insurance provider, we may need to file an appeal With your insurance company to re--process your claim as ln-Nelwork. We cannot do this until the attached torm called the "Designation oi Representative Form" is completed and returned to us. This lorm simply gives Genoptlx your authorization to file an appeal on your behalf. Please complete and sign the attached form and immediately send it bach to us in the postagepaid envelope provided. Failure to complete this form may result in a denial by your insurance company. As part or your insurance campany's standard protocol. you will receive an Explanation ot Benetits tees) statement indicating that Genoptix has billed your insurance provider. Please remember. an EOB is NOT a bill trom Genoptix. Please do not make any payments unless you receive a statement trom us. Wait for a bill from us. Once we have completed the billing and collection process With your insurance company, we will send you a on our letterhead. stating the amount you owe to Genopllx (it any) as your ill-network pathology coinsurance and/or deductible. Did you receive a check already? Some insurance companies will send a check directly to you tor our services. This check should be sent to Genoptix in order for us to deduct this lrorn your patient responsibility. Please contact us immediately at taooi 755--0302 and we will give you instructions on how to torward the payment to us ll you tail to send us this check. we bill you for this amount plus any coinsurance and/or deductible you may owe. It you have any questions about this letter. please do not call your physician's ottice. Call us directly at taco) 755-0802 and we will gladly assist you. Monday - Friday, 6 am - 4 pm tPacilic). Slnoerely. Your Genoptix Patient Administrator 9mm) "m "wt 2" Q'erk a n7 [Pr 830 H: OSCZ 'Fl /60 bit {7th EH) Rd Larlscad LA Deslgnauon or Represenrallve inumurizarion Form This form is to be tried out try a memw ii there is a request to reiaase the member's neaitn iniprrnanpn to anatner person or company or a request to appoint an Autnonzed Representative Please inctude as much tnrurmatturt as you can PART A. MEMBER INFORMATION Membertast name Memher lir$t name Mlchelle PART B. PERSON 0R COMPANV WHO CAN RECEIVE MV INFORMATION The toiiowlng peopie or companies nave tna right In receive my inlormatton They must pa is years at age or uider Please Check each box that :19 ties and entertirst and test name spouse (enter and iast name) parents tn you are aver ill - enter inst and iast namelsj) i [My dvmeslil: panner and last name) insurance broker or agent [enter tne nama uitne company and and iast name' rt you naye rt) rill/ty children (enter and last n2me[s]) Eomer (enter and iast name [ii you have it], ran; at company and now it's related in you) GENOPTIX li: IHMI (JAN Bl; lne lnionnallun \u be used or released Dy Empire cross and Blue Shield un nly Denali (uneck uniy UHB but) )0 Ali my inlovmalion. This can lnciude neatth' a diagnasm (name at illness or condition)' ciaims' doctors and other heaith Care provtders and itnanclai lniorntatlon (ilke hitting and doesn't include sensitive iniarmalion (see beiow) uniess is approved beiow OR LJ Only limited inlorrnation may be reieased tcnepn all bvxes beiow tnat appiy to you) jAppaai and enmiiment :lReterral Beneilts and coveraae Finanmai flTreatment DBliilng :JModlcat records :JDentai i ICialms and payment JDoctor and nospitai DViSion [name 01 litrless JPN-certification and pre'authonzatlon Pharmacy or condition) and procedure (tar traatment annmyais) mmnar- (treatment) 7 I also appruve the reiease oi the iuliowl'ng types 0t sensitive lntarrnatiorl by Empire Biue Cross and Biue Shieid [check boxes that appiy to you) i All sensitive inlarmalion; 0R ust about topics checked Amman UGenetlc testing jMental nealtn Abuse jl try or AIDS :lSexually liincas r] Alcanol/supstanpa aprrsa "'Maiarnity Servlces provided by Empire and/0r Emprre Assurance, inc ilcensees Biue Class and Biue Shleid Association an assaarattan at independent Blue Crass and Etna Shield plans Anthem UM Servrces Inc ts a separate company providing review services on penanpt Emprre PART D: PERSON OR COMPANY WHO CAN ACT AS MY AUTHORIZED REPRESENTATIVE The following person or company has the right to act as my Authorized Representative. An Authorized Representative is a person who you appoint to be your representative in carrying out a grievance or appeal. including any external review rights that may be available to you. They must be 18 years of age or older. Please also complete Part and above to authorize the release of your information to your Authorized Representative. Please check each box that applies and enter first and last name. spouse (enter first and last name) [My parents (if you are over 18 enter first and last name[s]) ElMy domestic partner (enter first and last name) insurance broker or agent (enter the name of the company and first and last name, if you have it) ElMy adult children (enter first and last name[s]) IOther (enter first and last name [if you have it]. name of company, and how it's related to you) GENOPTIX PART E: DATE YOUR APPROVAL EXPIRES If this document was not already withdrawn, this approval will end: At the conclusion of the appeals process. El One year from the signature date in Part G. Upon the date. event or condition described below (please provide details): PART F: PURPOSE OF THIS APPROVAL Kl To allow an individual to act as my Authorized Representative in carrying out a grievance or appeal, including any external review rights that may be available to me. El To disclose information at my request. PART G: REVIEW AND APPROVAL I have read the contents of this form. I understand. agree. and allow Empire Blue Cross and Blue Shield to the use and release of my information as have stated above. I also understand that signing this form is of my own free will. I understand that Empire Blue Cross and Blue Shield does not require that I sign this form in order for me to receive treatment or payment, or for enrollment or being eligible for benefits. have the right to withdraw this approval at any time by giving written notice of my withdrawal to Empire Blue Cross and Blue Shield. I understand that my withdrawing this approval will not affect any action taken before I do so. I also understand that information that's released may be given out by the person or group who receives it. If this happens. it may no longer be protected under the Privacy Rule. I am entitled to a copy of this form. Member signature or Designated Legal Representative/Guardian signature Date DESIGNATED LEGAL If this form is signed by someone other than the member or parent, such as a personal representative, legal representative or guardian on behalf of the member. please submit the following: A copy of a health care, general or Durable Power of Attorney; OR A court order or other documentation that shows custody or other legal documentation showing the authority of the legal representative to act on the member's behalf. Please complete the following: Legal representative (print full name) Legal relationship to member Legal representative street address City State code Signature Date Please return the completed form to: Attention Customer Service Empire Blue Cross and Blue Shield PO Box 1407 Church Street Station New York. NY 10008-1407 Be sure to keep a copy of this form for your records. FOR RECIPIENT 0F SUBSTANCE ABUSE INFORMATION This information has been disclosed to you from records protected by Federal Confidentiality of Alcohol or Drug Abuse Patient Records rules (42 CFP part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT suf?cient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient, 2112' Implemented 3/12: Revised 05:12 DESIGNATION OF PERSONAL REPRESENTATIVE You may deslgnate a personal represenlallve who act an your behalf In maklng declslons relaled to health care, Includes treatment and payment Issues Individual can be a famlly member' frlend' lawyer or unrelated party Please print neatly to ensure correct and prompt processing. We reserve the right to return any illegible or form. 1) I authorize: GENOPTIX MEDICAL LABORATORY (HEALTH INSURANCE PLANICOMPANV) 2) To release the records of: 3) I hereby designate the following individualls) as my personal representative: Name of Address Olly, State le Telephone Name of Address Clty, Stale le Telephone Name of lnleldual Address City' State, Zip Telephone ll rm; lriln 1040710 Please read each of the following statements carefully before signing this document. 1. I understand that this designation Will expire when my golicy ends unless I indicate an expiration date or revoke it Date to expire I understand that this designation is voluntary and being made at my request. I understand that the released Information may no longer be protected by federal privacy laws and may be redisclosed by the individual or organization that receives the information 4' I understand thatl may refuse to sign this designation form My healthcare provider riot condition treatment and my health plan Will not condition payment enrollment, or eligibility on my signing this designation 5' I understand thatl may revoke this designation of personal representative at any time by sending a written notification to the Privacy Office at the address listed below and this revocation Will be effective for future uses and disclosures of protected health information. . Howeveri further understand that this revocation Will not be effective for information that my health plan has already used or disclosed. relying on this designation Signature: Date: if the person signing this form is not the memberi or the parent/guardian of a dependent under the age of 18, you must attach a full copy of the official document indicating your legal authority to sign on behalf of the member (i Power of Attorney, Court Assigned Guardiani Personal Representative. etc) mental health orsubstaiice abuse iniunnaiiun wnian has been disclosed from medical or otherhealtn care records. may be protected by federal and/or siaie law vine records are so protected, Federal Regulallun "2ch Part 2) pron-ms the recipient ol the iniurrnaiiun ironi making any furtherdisclosure D'thls iniumiaiinn unless Such disclosure is expressly by me written consent ottrie person to who it pertains oras atheiWise permitted by 42 CPR Fan 2 A general authorization forthe release oi medical or other iniarmaiion is nor sulfimenl iorinis The Federal rules restrict any use oltne information to criminally investigate or prosecute any aieuriai or drug abuse patient Please mail or fax this authorization to: CareFirst BlueCross BlueShield Attention Privacy Office 10455 Mill Run Circle Owings Mills MD 21117 Fa 105056692 Privacy offlce@caretirst com Please keep a copy of this designation for your records