Preview
FILED: ONONDAGA COUNTY CLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021
NYSCEF DOC. NO. 69 RECEIVED NYSCEF: 06/24/2022
EXHIBIT Z
FILED: ONONDAGA COUNTY
DAP_0300370320200820_1740_0016-0001_000306_6-M-3BCLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021
NYSCEF DOC. NO. 69 RECEIVED NYSCEF: 06/24/2022
6909 164th Street, Suite 202
TADCHEV Fresh Meadows, NY 11365
- LAW F[RM, P.C. - T (718) 380-1200
F (718) 380-1400
08/14/2020
NATIONW1DE INSURANCE COMPANY OF AMERICA
P.O. BOX 26005
DAPHNE, AL 3d526
Re: Health Provider : ADVANT ORTHOCARE INC
hijured person : SVETLANA EPPS
Date of accident : 04/15/2020
Policy number : N/A
Claim number : 464160GK
Dates of service : 07/11/2020 To 08/07/2020
Amount in dispute : $2,315.50
File number : BT20-1 18434
Dear Sir/Madam:
We represent the above referenced health provider in the collection of the above referenced
matter.
Enclosed please find the health provider's proof of claim, including all bills,medical
records, and a duly executed assignment of benefits form signed by SVETLANA EPPS.
Kindly forward to our office a draft made payable to the health provider c/o The Tadchiev Law
Firm, P.C., pursuant to the no-fault rules and regulations. Please be advised that a copy of any
and all other correspondence relating to this claim should be forwarded to this office. However,
this is not a waiver of any requirement that must be complied with under the regulations
pertaining to requests directed to the provider or injured party. Failure to provide this office with
correspondence including verification requests or denials will result in prejudice to our client and
we will object to the document being proper at any subsequent arbitration or litigation. Please
give this matter your immediate attention.
Yours truly,
The Tadchiev- aw Firm, P.C.
Amy Zamb o Ayluardo
Administrative Assistant
FILED: ONONDAGA COUNTY
DAP_0300370320200820-1740_0016-0001_000307.6-M-3BCLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021
NYSCEF DOC. NO. 69 RECEIVED NYSCEF: 06/24/2022
35h
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE
(Thisform is not for verification
of hospital
treatment)
NAME AND ADDRESS OF INSURER OR SELF-INSURER NAME, ADDRESS, AND PHONE NUMBER OF INSURER'S CLAIMS
REPRESENTATIVE
Nationwide Insurance Company of America
PO BOX 26005
DAPHINE AL 36526
DATE POLICYHOLDER POLICY NUMBER ACCTDENT DATE C IM NUMBER
08/10/2020 EPPS SVETLANA 04/15/2020 464160GK
PROVIDER'SNAME AND ADDRESS
ADVANT ORTHOCARE INC.
5847 FRANCIS LEWIS BLVD, STE 17
BAYSIDE, NY, 11364-1601
Phone: 718-428-4600 Fax:
KINDLY COMPLETE AND SUBMITTHIS FORM AS SOON AS POSSIBLE. PLEASE NOTE, THISCOMPLETEDFORM
MUST BE SUBMITTED TO THE INSURER AS SOON AS REASONABLY POSSIBLE BUT NO LATER THAN
45 DAYS OR180 DAYSAFTER THE TREATMENT DATE. DEPENDING UPONTHE POUCY ENDORSEMENT IN EFFECT ATTHE
TIME 0F THE ACCIDENT
IFYOUAREUNSUREOFTHEAPPUCABLETIMEREQUIREMENT,KINDLY CONTACTTHE CI.AIMSREPRESENTATIVETO
DETERMINEWHICHDEADUNEISAPPUCABLETOTHIS CLAIM
IF YOU HAVE PREVIOUSLY SUBMITTED AN EARLIER REPORT ON THIS ACCIDENT, YOU NEED ONLY NOTE ANY CHANGES FROM
THE INFORMATION PREVIOUSLY FURNISHED AND ADDITIONAL CHARGES.
1. PATIENT'S NAME PATIENT'S ADDRESS
EPPS SVETLANA 305 OCEAN PARKWAY BROOKLYN NY
2. DATE OF BIRTH 3. SEX 4. OCCUPATION (IF KNOWN)
12/24/1979
5..DIAGNOSIS AND CONCURRENT CONDITIONS
1. 4.
2. 5.
3. 6. M25.562 - PAIN IN THE LEFT KNEE
6. WHEN DID SYMPTOMS FIRST APPEAR? 7 WHEN DID PATIENT FIRST CONSULT YOU FOR THIS CONDITION?
Date Date N/A
8. HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION?
Yes No X JF Yes, statewhen and describe:
9. IS CONDITION SOLELY A RESULT OF THIS AUTOMOBILE ACCIDENT?
Yes X No IF No, explain;
10. IS CONDITION DUE TO IN JURY ARISING OUT OF PATIENT'S EMPLOYMENT?
Yes No X
1 1.WILL INJURY RESULT IN SIGNIFICANT DISFIGUREMENT OR PERMANENT DISABILITY?
Yes No NOT DETERMINABLE AT THIS TIME X
IF Yes, describe:
12. PATIENT WAS DISABLED (UNABLE TO WORK) 13. IF STILLDISABLED THE PATIENT SHOULD BE ABLE TO
RETURN TOWORK ON:
From: Through: Date:
NYSFORM3NF (Rev 1/2004)
Page 1 Of 4
FILED: ONONDAGA COUNTY
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NYSCEF DOC. NO. 69 RECEIVED NYSCEF: 06/24/2022
VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE
14. WILL THE PATIENT REQ UIRE REHABILITATION AND/OR OCCUPATIONAL THERAPY AS A RESULT OF THE
INJURIES SUSTAINED IN THIS ACCIDENT?
Yes No IF YES, describe your recommendation below:
N/A
15. REPORT OF SERVICES RENDERED-- ATTACH ADDITIONAL SHEETS IF NECESSARY
DATE OF PLACE OF SERVICE DESCRIPTION OF TREATMENT OR HEALTH FEE SCHE DULE CHARGES
SERVICE INCLUDING ZIP CODE SERVICE RENDERED, MAKE.MODEL. TREATMENT CODE SUMMARY
07/11/2020 HOME SHEEPSKIN PAD E0188 Qty: 1 19.50
-
HOME CPM FOR THE KNEE EO935 Qty: 28 2296.00
07
TOTAL CHARGES TO DATES: 2315.50
16. I F TREATING PROVIDER IS D1FFERENT THAN BILLING PROVIDER COMPLETE THE FOLLOW1F G:
TREATING PROVIDER's NAME T1TLE LICENSE OR CERTIFICATION BUSINESS RELATIONÔHIP
ND. CHECK APPLICABLE BOX
EMPLOYEE INDEPENDENT OTHER(SPECIFY)
cONTRAcTOR
17. IFTHE PROVIDER OF SERVICE IS A PROFESSIONAL SERVICE CORPORATION OR DOING BUSINESS UNDER AN ASSUMED NAME
(DBA),LIST THE OWNER AND PROFESSIONAL LICENSING CREDENTIALS OF ALL OWNERS (Providean additional
attachmentif
necessary).
President: igor ilyasov LIC #
18. IS PATIENTSTILL UNDER YOUR CARE FOR THIS CONDITION? YES X NO
19. ESTIMATED DURATION OF FUTURE TREATMENT N/A
PATIENT: Your healthprovidermay agree to acceptpayment for health
servicesperformed frorn
directly ( Authorization
your insurer to Pay
Benefits) so thatyou
are not required
to make paymenttothe healthprovider
atthe timeofservice.Suchagreementisoption I on the palt of the
healthproviderand mustbe signed by bothpatient
and healthprovider.
You may use the optional
authorization
language providedbelow,by
checkingoff the designated
spotin item
20 of this fonn.
20. (IFYOU HAV) CHOSEN TO AUTHORIZE THE DIRECTPAYMEliT QF BENEFITS BY CHECKING THIS QPTION, YÇY IpY NOT
ALSO ENTER INTO AN ASSIGNMENT OF BENEFITS CONTAINED IN # 1)
AUTHORIZATION TO PAY BENEFITS
I AUTHORIZE PAYMENT OF HEALTH BENEFITS TO THE UNDERSIGNED HEALTH CARE PROVIDER OR SUPPLIER O SERVICES
DESCRIBED BELOW. I RETAIN ALL RIGHTS, PRIVILEGES AND REMEDIES TO WHICH I AMENTITLED UNDER ARTIC E 51 (THE
NO-FAULT PROVISION) OF THE INSURANCE LAW.
PATIENT NAME EPPS SVETLANA SIGNATURE DATE
NYSFORM3NF (Rev 2/2004)
Page 2 of4
FILED: ONONDAGA COUNTY CLERK
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NYSCEF DOC. NO. 69 RECEIVED NYSCEF: 06/24/2022
VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERV>CE
PATIENT: Your healthprovidermay agree to have you assign
your right to No-Fault from
benefits your insurer to yodr
directly healthprovider
(Assignmentof Benefitsh
If youand your health
provideragree of benefits,
to an assignment you mustboth sign the agreemeni
containedin # 21
NF-AOB
or the prescribed form or its equivalent.
The language contained of benefits
in the assignment is mandatoryand mak not be altered
or
language added to this writtenagreement I
avoidedby any other agreement or other
21. K (IF YOU HAVE CHOSEN TO ASSIGN YOUR BENEFITS TO THE HEALTH PROVIDER BY CHECKING THIS OhION,YOU MAY
NOT Al,SO ENTER INTO AN AUTHORIZATION TO PAY BENEFITS CONTAINED IN ITEM #20 ABOVE)
ASSIGNMENT OF NO-FAULT BENEFITS:
I HEREBY ASSIGN TO THE HEALTH CARE PROVIDER INDICATED BELOW ALL RIGHTS, PRIVILEGES AND REMEDIES TO PAYMENT
FOR HEALTH CARE SERVICES PROVIDED BY THE ASSIGNEE TO WHICH I AMENTITLED UNDER ARTICLE 51 (THE NO-FAULT
STATUTE) OF THE INSURANCE LAW. THE ASSIGNEE HEREBY CERTIFIES THAT THEY HAVE NOT RECElVED ANY PAYMENT FROM
OR ON BEHALF OF THE ASSIGNOR AND SHALL NOT PURSUE PAYMENT DIRECTLY FROM THE ASSIGNOR FOR SERVICES
PROVIDED BY SAID ASSIGNEE FOR INJURIES SUSTAINED DUE TO THE MOTOR VEHICLE ACCIDENT, NOTWITHSTANDING ANY
OTHER AGREEMENT TO THE CONTRARY. THIS AGREEMENT MAY BE REVOKED BY THE ASSIGNEE WHEN BENEFITS ARE NOT
PAYABLE BASED UPON THE ASSIGNOR'S LACK OF COVERAGE AND/OR VIOLATION OF A POLICY CONDITION DUE OTHE ACTIONS
OR CONDUCT OF THE ASSIGNOR
PATIENT NAME EPPS SVETLANA SIGNATURE ON FILE DATE
ADVANT' SIGNAME ON RE DATE
PROVIDER NAME ORTHOCARE
INC.
HAS AN ORIGINAL AUTHORIZATION OR ASSIGNMENT PREVIOUSLY
BEEN EXECUTED? YES X NO
IS THE ORIGINAL SIGNATURE OF THE PARTIES ON FILE? YES X NO
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN
APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE
BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEAD NG.
INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION
OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO lylAKE A FALSE
REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCI MENT AGENCY,
THE DEPARTMENT OF MOTOR VEMICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME, AND SHALL ALSO BE SUBJECT TO A CML PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE
SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLAT.N.
DATE PROVIDER SIGNATURE IRS/TIN IDENTIFICATION NO. WCB RATING CODE
IF NONE, SPECIALTY
08/10/2020 igor ilyasov 47-2674951
*
The fee schedulecodes and rates displayed bill are,
on this In the provider's
view,the most appropriate
codesand rates for the services
rendered. of the fee schedule,
Due to the complexity the provider
encouragesthe insurer
not to rely on the provider's as there
interpretation, is
the possibility or codes
that the rates may be incorrect; the
rather, insureris encouragedto review
the fee scheduleand make an independent
determinationregardingthe appropriateness
of the fee codes herein.
and rates depicted
**
By listing the name of the provider
in this section,
the provider
is merely what the name
stating of Incorporation
Is as listed on the certificate filed
with the Secretary
of State. The provider
is not makingany representation whether
regarding or not it is in compliance
withthe licensing
laws
(BCL, EducationLaws, of New
etc.) of the state York, or as to its eligibility
to obtain insurance
no-fault benefits
under 11 NYCRR 65.
LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER
NYSFORMSNF(Rev 1/2004)
Page 3 of 4
FILED: ONONDAGA COUNTY CLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021
NYSCEF DOC. NO. 69 RECEIVED NYSCEF: 06/24/2022
EXPLANATION OF REVIEW QW0041338- EOBID -db
Archive Copy
New York
Claim Number: 464160-GK
Receive Date: 08/20/2020 Adjuster: pupilj1 - Jennifer Pupillo
Service Provider: 47-2674951 Date Of Loss: 04/15/2020
ADVANT ORTHOCARE INC Patient Account #:
5847 FRANCIS LEWIS BLVD STE 17
BAYSIDE NY 11364
Billing Provider: 47-2674951 Mail To Patient:
ADVANT ORTHOCARE INC EPPS, SVETLANA
5847 FRANCIS LEWIS BLVD 305 OCEAN PARKWAY APT 2K
STE 17
BAYSIDE NY 11364 BROOKLYN NY 11218
Provider Title: DME Carrier:
Provider Specialty: NATIONWIDE GENERAL INSURANCE COMPANY
PO BOX 26005
DAPHNE AL 36526
Dates Of Service: 07/11/2020 to 07/11/2020
ICD REF ICD POA IND DIAGNOSIS DESCRIPTION
1 M25.562 ICD-0 Pain in left knee
LINE DOS PROC MOD DESCRIPTION UNITS CHARGE *PEN PROVIDER EXPLANATION
CODE REDUCTION REIMBURSE
1 7/11/20 E0188 Synthetic sheepskin pad 1 19.50 0.00 0.00 NYME38
ICD Ref 1
2 7/11/20 E0935 Continuous passive mot exercise 28 2296.00 0.00 0.00 NYME38
devc knee only
ICD Ref 1
If you have any questions regarding payment, please contact your insurance carrier.
If you have questions regarding this Explanation of Review, please contact our Customer Service Department at 877-444-8763.
PO BOX 26005, DAPHNE, AL 36526
877.444.8763
Printed On --
01-Mar-2021
1:32 pm Page 1 of 5
FILED: ONONDAGA COUNTY CLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021
NYSCEF DOC. NO. 69464160-GK
RECEIVED NYSCEF: 06/24/2022
Claim Number -- Total Charges --$ 2,315.50 QW0041338- EOBID -db
Archive Copy
Billing Provider -- ADVANT ORTHOCARE INC
Total Reimbursement --$ 0.00
Service Provider -- ADVANT ORTHOCARE INC
Patient Name -- EPPS, SVETLANA 07/11/2020
Dates Of Service -- - 07/11/2020
Total Lines : 2 2315.50 0.00 0.00
If you have any questions regarding payment, please contact your insurance carrier.
If you have questions regarding this Explanation of Review, please contact our Customer Service Department at 877-444-8763.
PO BOX 26005, DAPHNE, AL 36526
877.444.8763
Printed On --
01-Mar-2021
1:32 pm Page 2 of 5
FILED: ONONDAGA COUNTY CLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021
NYSCEF DOC. NO. 69464160-GK
RECEIVED NYSCEF: 06/24/2022
Claim Number -- Total Charges --$ 2,315.50 QW0041338- EOBID -db
Archive Copy
Billing Provider -- ADVANT ORTHOCARE INC
Total Reimbursement --$ 0.00
Service Provider -- ADVANT ORTHOCARE INC
Patient Name -- EPPS, SVETLANA 07/11/2020
Dates Of Service -- - 07/11/2020
Reimbursement Amount : 0.00
Apportionment % :
Subtotal : 0.00
Less Deductible : 0.00
Limited Benefits/Copay : 0.00
Collateral Source/Healthcare Carrier Payment : 0.00
Plus Interest : 0.00
EOR Check Amount : 0.00
Allocated PIP Payment : 0.00
Allocated MedPay/Medical Expense Payment : 0.00
EXPLANATION EXPLANATION FOR THE REVIEW AMOUNT REF DOC_ID REF LINE NUMBER
NYME38 See explanation in the Comments section of this EOR and/or on page 4 of the NF10.
If you have any questions regarding payment, please contact your insurance carrier.
If you have questions regarding this Explanation of Review, please contact our Customer Service Department at 877-444-8763.
PO BOX 26005, DAPHNE, AL 36526
877.444.8763
Printed On --
01-Mar-2021
1:32 pm Page 3 of 5
FILED: ONONDAGA COUNTY CLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021
NYSCEF DOC. NO. 69464160-GK
RECEIVED NYSCEF: 06/24/2022
Claim Number -- Total Charges --$ 2,315.50 QW0041338- EOBID -db
Archive Copy
Billing Provider -- ADVANT ORTHOCARE INC
Total Reimbursement --$ 0.00
Service Provider -- ADVANT ORTHOCARE INC
Patient Name -- EPPS, SVETLANA 07/11/2020
Dates Of Service -- - 07/11/2020
Comments :NYME38: Pursuant to 11 NYCRR 65-3.8(b) New York State Insurance Regulation 68-C an insurer may issue a denial if, more than 120
calendar days after the initial request for verification, the applicant has not submitted all such verification under the applicant’s control or possession or
written proof providing reasonable justification for the failure to comply. Nationwide denied Svetlana Epp’s claim for failure to provide the requested
verification or written proof providing reasonable justification for the failure to comply within 120 calendar days after our initial request on September 30,
2020. Additionally, Sveltana Epp’s claim was also denied pursuant to 11 NYCRR 65-3.12(a)(1) and 11 NYCRR 65-3.12(10)(c). Therefore, based on the
aforementioned, your claim for services is denied.
If you have any questions regarding payment, please contact your insurance carrier.
If you have questions regarding this Explanation of Review, please contact our Customer Service Department at 877-444-8763.
PO BOX 26005, DAPHNE, AL 36526
877.444.8763
Printed On --
01-Mar-2021
1:32 pm Page 4 of 5
FILED: ONONDAGA COUNTY CLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021
NYSCEF DOC. NO. 69464160-GK
RECEIVED NYSCEF: 06/24/2022
Claim Number -- Total Charges --$ 2,315.50 QW0041338- EOBID -db
Archive Copy
Billing Provider -- ADVANT ORTHOCARE INC
Total Reimbursement --$ 0.00
Service Provider -- ADVANT ORTHOCARE INC
Patient Name -- EPPS, SVETLANA 07/11/2020
Dates Of Service -- - 07/11/2020
"If payment is due, check will be mailed under separate cover. Cashing this check will not forfeit your appeal
rights. The amount shown should be considered full payment for service dates indicated, unless additional
information is requested. WARNING: "ANY PERSON WHO KNOWINGLY AND WITH INTENT TO
DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL
INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR
THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND
ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR
KNOWINGLY ASSISTS, ABETS, SOLICITS, OR CONSPIRES WITH ANOTHER TO MAKE A FALSE
REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A
LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE
COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF
THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION." APPEAL PROCESS:
Please submit the following to the address listed below: 1. A copy of this Explanation of Reimbursement , 2.
The reasons that you disagree with the reimbursement, 3. A copy of all supporting medical documentation
concerning this appeal."
If you have any questions regarding payment, please contact your insurance carrier.
If you have questions regarding this Explanation of Review, please contact our Customer Service Department at 877-444-8763.
PO BOX 26005, DAPHNE, AL 36526
877.444.8763
Printed On --
01-Mar-2021
1:32 pm Page 5 of 5
FILED: ONONDAGA COUNTY CLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
NYSCEF DOC. NO. 69 RECEIVED NYSCEF: 06/24/2022
DENIAL OF CLAIM FORM
TO INSURER: Complete this form, including item 33. Send two copies to applicant. Upon the request of the injured person, the insurer should
send to the injured person a copy of all prescribed claim forms and documents submitted by or on behalf of the injured person.
NAME, ADDRESS AND NAIC NATIONWIDE GENERAL INSURANCE COMPANY
NUMBER OF INSURER OR
PO BOX 26005
NAME AND ADDRESS OF For American Arbitration Association use
SELF-INSURER DAPHNE, AL 36526 23760
Doc ID: QW0041338
A. POLICYHOLDER B. POLICY NUMBER C. DATE OF ACCIDENT D. INJURED PERSON
JOHANN BENEDICT BARKER 6631J 066695 04/15/2020 Epps, Svetlana
E. CLAIM NUMBER F. APPLICANT FOR BENEFITS (Name and address) 305 OCEAN PARKWAY APT 2K
Advant Orthocare Inc BROOKLYN, NY 11218
464160-GK
5847 Francis Lewis BlvdSte 17
G. AS ASSIGNEE
Bayside, NY 11364
1.Yes x 2.No o
TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO CONTEST THIS DENIAL
YOU ARE ADVISED THAT FOR REASONS NOTED BELOW:
o 1. Your entire claim is denied as follows:
x 2. A portion of your claim is denied as follows:
o A. Loss of Earnings: $ o D. Interest: $
x B. Health Service Benefits: $ 2315.50o E. Attorney's Fees: $
o C. Other Necessary Expenses: $ o F. Death Benefit: $
REASON(S) FOR DENIAL OF CLAIM (Check reasons and explain below in item 33)
POLICY ISSUES
o 3. Policy not in force on date of accident
o 6. Injured person not an "Eligible Injured Person"
o 4. Injured person excluded under policy conditions or exclusion
o 5. Policy conditions violated: o 7. Injuries did not arise out of use or operation of a motor vehicle
o a. No reasonable justification given for late notice of claim.
o 8. Claim not within the scope of your election under
o b. Reasonable justification not established. You may qualify for special
Optional Basic Economic Loss coverage
expedited arbitration. See page 2 of this form for instructions.
LOSS OF EARNINGS BENEFITS DENIED
o 9. Period of disability contested: period in dispute o 11. Exaggerated earnings claim of $ per month denied
From Through o 12. Statutory offset taken
o 10. Claimed loss not proven o 13. Other, explained below:
OTHER REASONABLE AND NECESSARY EXPENSES DENIED
o 14. Amount of claim exceeds daily limit of coverage o 16. Incurred after one year from date of accident
o 15. Unreasonable or unnecessary expenses o 17. Other, explained below
HEALTH SERVICE BENEFITS DENIED
o 20. Treatment not related to accident
x 18. Fees not in accordance with fee schedules
o 21. Unnecessary treatment, service or hospitalization
o 19. Excessive treatment, service or hospitalization From Through
From Through x 22. Other, explained below:
COMPLETE ITEMS 23 THROUGH 32 IF CLAIM FOR HEALTH SERVICE BENEFITS IS DENIED
23. Provider of Health Service (Name, Address and Zip Code) 25. Period of bill-treatment dates
28. Date final verification requested
31. Amount paid by insurer
ADVANT ORTHOCARE INC 07/11/2020 - 07/11/2020 10/08/2020
5847 Francis Lewis BLVD STE 17 26. Date of bill 29. Date final verification received
32. Amount in dispute
Bayside, NY 11364 08/10/2020
24. Type of service rendered 27. Date received by insurer 30. Amount of bill
2315.50
Medical 08/20/2020 2315.50
SEE ATTACHED EOR FOR EXPLANATION OF REDUCTION
33. State reason for denial, fully and explicitly (attach extra sheets if needed):
See the attached explanation of review for docid PUPILJ1 - JENNIFER PUPILLO
QW0041338
Name, and Title of Representative of Insurer
DATE 03/01/2021 PO BOX 26005
TELEPHONE NUMBER: 315.453.3476 EXT. DAPHNE, AL 36526
Name and address of Insurer claim processor (Third Party Administrator), if applicable
NYS FORM NF-10 (Rev 1/2017) Page 1 of 4
FILED: ONONDAGA COUNTY CLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021
NYSCEF DOC. NO. 69 DENIAL OF CLAIM FORM - PAGE TWO RECEIVED NYSCEF: 06/24/2022
IF YOU WISH TO CONTEST THIS DENIAL, YOU HAVE THE FOLLOWING OPTIONS:
1. Should you wish to take this matter up with the New York State Department of Financial Services, you may file with the Department either on its website at
http://www.dfs.ny.gov/consumer/fileacomplaint.htm or you may write to or visit the Consumer Assistance Unit, Financial Frauds and Consumer Protection Division,
New York State Department of Financial Services, at: One State Street, New York, NY 10004; One Commerce Plaza, Albany, NY 12257; 1399 Franklin Avenue,
Garden City, NY 11530, or Walter J. Mahoney Office Building, 65 Court Street, Buffalo, NY 14202.
Although the Department of Financial Services will attempt to resolve disputed claims, it cannot order or require an insurer to pay a disputed claim. If you wish to
file a written complaint, send one copy of this Denial of Claim Form with copies of other pertinent documents with a letter fully explaining your complaint to the
Department of Financial Services at one of the above addresses.
If you choose this option, you may at a later date still submit this dispute to arbitration or bring a lawsuit; or
2. You may submit this dispute to arbitration. If you wish to submit this claim to arbitration, then mail or e-mail a copy of this Denial of Claim Form along
with a complete submission of all other pertinent documents and a table of contents listing your submissions, in duplicate together with a $40 filing fee, payable by
check, money order, or credit card to the American Arbitration Association (AAA) to:
AMERICAN ARBITRATION ASSOCIATION (AAA)
NEW YORK INSURANCE CASE MANAGEMENT CENTER
120 BROADWAY
NEW YORK, NEW YORK 10271
nyicmc.filingsubmissions@adr.org
Please contact the American Arbitration Association's customer service department at (917) 438-1660 with any questions about case filing.
A complete copy of this filing, listing all bills and proofs as well as a table of contents listing your submissions must be provided to the AAA and the insurer at the
time of filing for arbitration. The filing must be complete with all necessary documentation, as any late submission may not be admissible at arbitration. The filing
fee will be returned to you if the arbitrator awards you any portion of your claim. However, you may be assessed the costs of the arbitration proceeding if the
arbitrator finds your claim to be frivolous, without factual or legal merit or was filed for the purpose of harassing the respondent. The decision of an arbitrator is
binding, except for limited grounds for review set forth in the Law and regulations promulgated thereunder.
If you are contesting the denial of claim and wish to submit the dispute to arbitration, state on accompanying sheets the reason(s) you believe the denied or overdue
benefits should be paid. Attach proof of disability and verification of loss of earnings in dispute, sign below, and send the completed form to the American
Arbitration Association at the address given in item 2 above.
Loss of Earning : Date claim made:_____________________ Gross Earning per month
$_______________________
___________Through____________ Amount Claimed : $_____________________________
Period of dispute: From
Health Service: (Attach bills in dispute and list each one separately)
Name of Provider Date of Service Amount of Bill Amount in Dispute Date Claim Mailed
Other Necessary Expense : (Attach bills in dispute and list each one separately)
Type of Expense Claimed Amount Claimed Date Incurred Date Claim Mailed Amount in Dispute
Other: (attach additional sheet if necessary)
i Upon your request, if you file for arbitration within 90 days of the date of this denial or the claim becoming overdue, your case will be scheduled for
arbitration on a priority basis.
i You qualify for special expedited arbitration if the insurer has determined that your written justification for submitting late notice of claim failed to
meet a "reasonableness standard". Your specific request for special expedited arbitration must be filed within 30 days of the date of denial. Your filing
must be complete and contain all information that you are submitting at the time of filing.
NYS FORM NF-10 (Rev 1/2017) Page 2 of 4
FILED: ONONDAGA COUNTY CLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021
NYSCEF DOC. NO. 69 RECEIVED NYSCEF: 06/24/2022
DENIAL OF CLAIM FORM - PAGE THREE
3. You may bring a lawsuit to recover the amount of benefits you claim to be entitled to.
THE UNDERSIGNED AFFIRMS AND CERTIFIES AS TRUE UNDER THE PENALTY OF PERJURY THAT THIS FILING IS BEING MADE IN
GOOD FAITH AND THAT UPON INFORMATION, BELIEF AND REASONABLE INQUIRY THE DOCUMENTS BEING SUBMITTED
HEREWITH ARE NOT FRAUDULENT AND THAT EXACT COPIES OF ALL DOCUMENTS PROVIDED HEREWITH HAVE BEEN MAILED
TO THE INSURER AGAINST WHOM THE ARBITRATION IS BEING REQUESTED. UNLESS DISCLOSED WITH THIS SUBMISSION, THE
DISPUTED AMOUNTS REMAIN UNPAID TO THE APPLICANT BY ANY PAYOR AND THERE HAS BEEN NO OTHER FILING OF AN
ARBITRATION REQUEST OR LAWSUIT TO RESOLVE THE DISPUTED MATTERS CONTAINED IN THIS SUBMISSION.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN
APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL
INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH
SUCH APPLICATION OR CLAIM, KNOWI
Preview
FILED: ONONDAGA COUNTY CLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021 NYSCEF DOC. NO. 69 RECEIVED NYSCEF: 06/24/2022 EXHIBIT Z FILED: ONONDAGA COUNTY DAP_0300370320200820_1740_0016-0001_000306_6-M-3BCLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021 NYSCEF DOC. NO. 69 RECEIVED NYSCEF: 06/24/2022 6909 164th Street, Suite 202 TADCHEV Fresh Meadows, NY 11365 - LAW F[RM, P.C. - T (718) 380-1200 F (718) 380-1400 08/14/2020 NATIONW1DE INSURANCE COMPANY OF AMERICA P.O. BOX 26005 DAPHNE, AL 3d526 Re: Health Provider : ADVANT ORTHOCARE INC hijured person : SVETLANA EPPS Date of accident : 04/15/2020 Policy number : N/A Claim number : 464160GK Dates of service : 07/11/2020 To 08/07/2020 Amount in dispute : $2,315.50 File number : BT20-1 18434 Dear Sir/Madam: We represent the above referenced health provider in the collection of the above referenced matter. Enclosed please find the health provider's proof of claim, including all bills,medical records, and a duly executed assignment of benefits form signed by SVETLANA EPPS. Kindly forward to our office a draft made payable to the health provider c/o The Tadchiev Law Firm, P.C., pursuant to the no-fault rules and regulations. Please be advised that a copy of any and all other correspondence relating to this claim should be forwarded to this office. However, this is not a waiver of any requirement that must be complied with under the regulations pertaining to requests directed to the provider or injured party. Failure to provide this office with correspondence including verification requests or denials will result in prejudice to our client and we will object to the document being proper at any subsequent arbitration or litigation. Please give this matter your immediate attention. Yours truly, The Tadchiev- aw Firm, P.C. Amy Zamb o Ayluardo Administrative Assistant FILED: ONONDAGA COUNTY DAP_0300370320200820-1740_0016-0001_000307.6-M-3BCLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021 NYSCEF DOC. NO. 69 RECEIVED NYSCEF: 06/24/2022 35h NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE (Thisform is not for verification of hospital treatment) NAME AND ADDRESS OF INSURER OR SELF-INSURER NAME, ADDRESS, AND PHONE NUMBER OF INSURER'S CLAIMS REPRESENTATIVE Nationwide Insurance Company of America PO BOX 26005 DAPHINE AL 36526 DATE POLICYHOLDER POLICY NUMBER ACCTDENT DATE C IM NUMBER 08/10/2020 EPPS SVETLANA 04/15/2020 464160GK PROVIDER'SNAME AND ADDRESS ADVANT ORTHOCARE INC. 5847 FRANCIS LEWIS BLVD, STE 17 BAYSIDE, NY, 11364-1601 Phone: 718-428-4600 Fax: KINDLY COMPLETE AND SUBMITTHIS FORM AS SOON AS POSSIBLE. PLEASE NOTE, THISCOMPLETEDFORM MUST BE SUBMITTED TO THE INSURER AS SOON AS REASONABLY POSSIBLE BUT NO LATER THAN 45 DAYS OR180 DAYSAFTER THE TREATMENT DATE. DEPENDING UPONTHE POUCY ENDORSEMENT IN EFFECT ATTHE TIME 0F THE ACCIDENT IFYOUAREUNSUREOFTHEAPPUCABLETIMEREQUIREMENT,KINDLY CONTACTTHE CI.AIMSREPRESENTATIVETO DETERMINEWHICHDEADUNEISAPPUCABLETOTHIS CLAIM IF YOU HAVE PREVIOUSLY SUBMITTED AN EARLIER REPORT ON THIS ACCIDENT, YOU NEED ONLY NOTE ANY CHANGES FROM THE INFORMATION PREVIOUSLY FURNISHED AND ADDITIONAL CHARGES. 1. PATIENT'S NAME PATIENT'S ADDRESS EPPS SVETLANA 305 OCEAN PARKWAY BROOKLYN NY 2. DATE OF BIRTH 3. SEX 4. OCCUPATION (IF KNOWN) 12/24/1979 5..DIAGNOSIS AND CONCURRENT CONDITIONS 1. 4. 2. 5. 3. 6. M25.562 - PAIN IN THE LEFT KNEE 6. WHEN DID SYMPTOMS FIRST APPEAR? 7 WHEN DID PATIENT FIRST CONSULT YOU FOR THIS CONDITION? Date Date N/A 8. HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION? Yes No X JF Yes, statewhen and describe: 9. IS CONDITION SOLELY A RESULT OF THIS AUTOMOBILE ACCIDENT? Yes X No IF No, explain; 10. IS CONDITION DUE TO IN JURY ARISING OUT OF PATIENT'S EMPLOYMENT? Yes No X 1 1.WILL INJURY RESULT IN SIGNIFICANT DISFIGUREMENT OR PERMANENT DISABILITY? Yes No NOT DETERMINABLE AT THIS TIME X IF Yes, describe: 12. PATIENT WAS DISABLED (UNABLE TO WORK) 13. IF STILLDISABLED THE PATIENT SHOULD BE ABLE TO RETURN TOWORK ON: From: Through: Date: NYSFORM3NF (Rev 1/2004) Page 1 Of 4 FILED: ONONDAGA COUNTY DAP_0300370320200820_1740_0016-0001-000308_6-M-3BCLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021 NYSCEF DOC. NO. 69 RECEIVED NYSCEF: 06/24/2022 VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE 14. WILL THE PATIENT REQ UIRE REHABILITATION AND/OR OCCUPATIONAL THERAPY AS A RESULT OF THE INJURIES SUSTAINED IN THIS ACCIDENT? Yes No IF YES, describe your recommendation below: N/A 15. REPORT OF SERVICES RENDERED-- ATTACH ADDITIONAL SHEETS IF NECESSARY DATE OF PLACE OF SERVICE DESCRIPTION OF TREATMENT OR HEALTH FEE SCHE DULE CHARGES SERVICE INCLUDING ZIP CODE SERVICE RENDERED, MAKE.MODEL. TREATMENT CODE SUMMARY 07/11/2020 HOME SHEEPSKIN PAD E0188 Qty: 1 19.50 - HOME CPM FOR THE KNEE EO935 Qty: 28 2296.00 07 TOTAL CHARGES TO DATES: 2315.50 16. I F TREATING PROVIDER IS D1FFERENT THAN BILLING PROVIDER COMPLETE THE FOLLOW1F G: TREATING PROVIDER's NAME T1TLE LICENSE OR CERTIFICATION BUSINESS RELATIONÔHIP ND. CHECK APPLICABLE BOX EMPLOYEE INDEPENDENT OTHER(SPECIFY) cONTRAcTOR 17. IFTHE PROVIDER OF SERVICE IS A PROFESSIONAL SERVICE CORPORATION OR DOING BUSINESS UNDER AN ASSUMED NAME (DBA),LIST THE OWNER AND PROFESSIONAL LICENSING CREDENTIALS OF ALL OWNERS (Providean additional attachmentif necessary). President: igor ilyasov LIC # 18. IS PATIENTSTILL UNDER YOUR CARE FOR THIS CONDITION? YES X NO 19. ESTIMATED DURATION OF FUTURE TREATMENT N/A PATIENT: Your healthprovidermay agree to acceptpayment for health servicesperformed frorn directly ( Authorization your insurer to Pay Benefits) so thatyou are not required to make paymenttothe healthprovider atthe timeofservice.Suchagreementisoption I on the palt of the healthproviderand mustbe signed by bothpatient and healthprovider. You may use the optional authorization language providedbelow,by checkingoff the designated spotin item 20 of this fonn. 20. (IFYOU HAV) CHOSEN TO AUTHORIZE THE DIRECTPAYMEliT QF BENEFITS BY CHECKING THIS QPTION, YÇY IpY NOT ALSO ENTER INTO AN ASSIGNMENT OF BENEFITS CONTAINED IN # 1) AUTHORIZATION TO PAY BENEFITS I AUTHORIZE PAYMENT OF HEALTH BENEFITS TO THE UNDERSIGNED HEALTH CARE PROVIDER OR SUPPLIER O SERVICES DESCRIBED BELOW. I RETAIN ALL RIGHTS, PRIVILEGES AND REMEDIES TO WHICH I AMENTITLED UNDER ARTIC E 51 (THE NO-FAULT PROVISION) OF THE INSURANCE LAW. PATIENT NAME EPPS SVETLANA SIGNATURE DATE NYSFORM3NF (Rev 2/2004) Page 2 of4 FILED: ONONDAGA COUNTY CLERK DAP_0300370320200820-1740__0016-0001_000309-6-M-3B 06/24/2022 02:55 PM INDEX NO. 007351/2021 NYSCEF DOC. NO. 69 RECEIVED NYSCEF: 06/24/2022 VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERV>CE PATIENT: Your healthprovidermay agree to have you assign your right to No-Fault from benefits your insurer to yodr directly healthprovider (Assignmentof Benefitsh If youand your health provideragree of benefits, to an assignment you mustboth sign the agreemeni containedin # 21 NF-AOB or the prescribed form or its equivalent. The language contained of benefits in the assignment is mandatoryand mak not be altered or language added to this writtenagreement I avoidedby any other agreement or other 21. K (IF YOU HAVE CHOSEN TO ASSIGN YOUR BENEFITS TO THE HEALTH PROVIDER BY CHECKING THIS OhION,YOU MAY NOT Al,SO ENTER INTO AN AUTHORIZATION TO PAY BENEFITS CONTAINED IN ITEM #20 ABOVE) ASSIGNMENT OF NO-FAULT BENEFITS: I HEREBY ASSIGN TO THE HEALTH CARE PROVIDER INDICATED BELOW ALL RIGHTS, PRIVILEGES AND REMEDIES TO PAYMENT FOR HEALTH CARE SERVICES PROVIDED BY THE ASSIGNEE TO WHICH I AMENTITLED UNDER ARTICLE 51 (THE NO-FAULT STATUTE) OF THE INSURANCE LAW. THE ASSIGNEE HEREBY CERTIFIES THAT THEY HAVE NOT RECElVED ANY PAYMENT FROM OR ON BEHALF OF THE ASSIGNOR AND SHALL NOT PURSUE PAYMENT DIRECTLY FROM THE ASSIGNOR FOR SERVICES PROVIDED BY SAID ASSIGNEE FOR INJURIES SUSTAINED DUE TO THE MOTOR VEHICLE ACCIDENT, NOTWITHSTANDING ANY OTHER AGREEMENT TO THE CONTRARY. THIS AGREEMENT MAY BE REVOKED BY THE ASSIGNEE WHEN BENEFITS ARE NOT PAYABLE BASED UPON THE ASSIGNOR'S LACK OF COVERAGE AND/OR VIOLATION OF A POLICY CONDITION DUE OTHE ACTIONS OR CONDUCT OF THE ASSIGNOR PATIENT NAME EPPS SVETLANA SIGNATURE ON FILE DATE ADVANT' SIGNAME ON RE DATE PROVIDER NAME ORTHOCARE INC. HAS AN ORIGINAL AUTHORIZATION OR ASSIGNMENT PREVIOUSLY BEEN EXECUTED? YES X NO IS THE ORIGINAL SIGNATURE OF THE PARTIES ON FILE? YES X NO ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEAD NG. INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO lylAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCI MENT AGENCY, THE DEPARTMENT OF MOTOR VEMICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CML PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLAT.N. DATE PROVIDER SIGNATURE IRS/TIN IDENTIFICATION NO. WCB RATING CODE IF NONE, SPECIALTY 08/10/2020 igor ilyasov 47-2674951 * The fee schedulecodes and rates displayed bill are, on this In the provider's view,the most appropriate codesand rates for the services rendered. of the fee schedule, Due to the complexity the provider encouragesthe insurer not to rely on the provider's as there interpretation, is the possibility or codes that the rates may be incorrect; the rather, insureris encouragedto review the fee scheduleand make an independent determinationregardingthe appropriateness of the fee codes herein. and rates depicted ** By listing the name of the provider in this section, the provider is merely what the name stating of Incorporation Is as listed on the certificate filed with the Secretary of State. The provider is not makingany representation whether regarding or not it is in compliance withthe licensing laws (BCL, EducationLaws, of New etc.) of the state York, or as to its eligibility to obtain insurance no-fault benefits under 11 NYCRR 65. LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER NYSFORMSNF(Rev 1/2004) Page 3 of 4 FILED: ONONDAGA COUNTY CLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021 NYSCEF DOC. NO. 69 RECEIVED NYSCEF: 06/24/2022 EXPLANATION OF REVIEW QW0041338- EOBID -db Archive Copy New York Claim Number: 464160-GK Receive Date: 08/20/2020 Adjuster: pupilj1 - Jennifer Pupillo Service Provider: 47-2674951 Date Of Loss: 04/15/2020 ADVANT ORTHOCARE INC Patient Account #: 5847 FRANCIS LEWIS BLVD STE 17 BAYSIDE NY 11364 Billing Provider: 47-2674951 Mail To Patient: ADVANT ORTHOCARE INC EPPS, SVETLANA 5847 FRANCIS LEWIS BLVD 305 OCEAN PARKWAY APT 2K STE 17 BAYSIDE NY 11364 BROOKLYN NY 11218 Provider Title: DME Carrier: Provider Specialty: NATIONWIDE GENERAL INSURANCE COMPANY PO BOX 26005 DAPHNE AL 36526 Dates Of Service: 07/11/2020 to 07/11/2020 ICD REF ICD POA IND DIAGNOSIS DESCRIPTION 1 M25.562 ICD-0 Pain in left knee LINE DOS PROC MOD DESCRIPTION UNITS CHARGE *PEN PROVIDER EXPLANATION CODE REDUCTION REIMBURSE 1 7/11/20 E0188 Synthetic sheepskin pad 1 19.50 0.00 0.00 NYME38 ICD Ref 1 2 7/11/20 E0935 Continuous passive mot exercise 28 2296.00 0.00 0.00 NYME38 devc knee only ICD Ref 1 If you have any questions regarding payment, please contact your insurance carrier. If you have questions regarding this Explanation of Review, please contact our Customer Service Department at 877-444-8763. PO BOX 26005, DAPHNE, AL 36526 877.444.8763 Printed On -- 01-Mar-2021 1:32 pm Page 1 of 5 FILED: ONONDAGA COUNTY CLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021 NYSCEF DOC. NO. 69464160-GK RECEIVED NYSCEF: 06/24/2022 Claim Number -- Total Charges --$ 2,315.50 QW0041338- EOBID -db Archive Copy Billing Provider -- ADVANT ORTHOCARE INC Total Reimbursement --$ 0.00 Service Provider -- ADVANT ORTHOCARE INC Patient Name -- EPPS, SVETLANA 07/11/2020 Dates Of Service -- - 07/11/2020 Total Lines : 2 2315.50 0.00 0.00 If you have any questions regarding payment, please contact your insurance carrier. If you have questions regarding this Explanation of Review, please contact our Customer Service Department at 877-444-8763. PO BOX 26005, DAPHNE, AL 36526 877.444.8763 Printed On -- 01-Mar-2021 1:32 pm Page 2 of 5 FILED: ONONDAGA COUNTY CLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021 NYSCEF DOC. NO. 69464160-GK RECEIVED NYSCEF: 06/24/2022 Claim Number -- Total Charges --$ 2,315.50 QW0041338- EOBID -db Archive Copy Billing Provider -- ADVANT ORTHOCARE INC Total Reimbursement --$ 0.00 Service Provider -- ADVANT ORTHOCARE INC Patient Name -- EPPS, SVETLANA 07/11/2020 Dates Of Service -- - 07/11/2020 Reimbursement Amount : 0.00 Apportionment % : Subtotal : 0.00 Less Deductible : 0.00 Limited Benefits/Copay : 0.00 Collateral Source/Healthcare Carrier Payment : 0.00 Plus Interest : 0.00 EOR Check Amount : 0.00 Allocated PIP Payment : 0.00 Allocated MedPay/Medical Expense Payment : 0.00 EXPLANATION EXPLANATION FOR THE REVIEW AMOUNT REF DOC_ID REF LINE NUMBER NYME38 See explanation in the Comments section of this EOR and/or on page 4 of the NF10. If you have any questions regarding payment, please contact your insurance carrier. If you have questions regarding this Explanation of Review, please contact our Customer Service Department at 877-444-8763. PO BOX 26005, DAPHNE, AL 36526 877.444.8763 Printed On -- 01-Mar-2021 1:32 pm Page 3 of 5 FILED: ONONDAGA COUNTY CLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021 NYSCEF DOC. NO. 69464160-GK RECEIVED NYSCEF: 06/24/2022 Claim Number -- Total Charges --$ 2,315.50 QW0041338- EOBID -db Archive Copy Billing Provider -- ADVANT ORTHOCARE INC Total Reimbursement --$ 0.00 Service Provider -- ADVANT ORTHOCARE INC Patient Name -- EPPS, SVETLANA 07/11/2020 Dates Of Service -- - 07/11/2020 Comments :NYME38: Pursuant to 11 NYCRR 65-3.8(b) New York State Insurance Regulation 68-C an insurer may issue a denial if, more than 120 calendar days after the initial request for verification, the applicant has not submitted all such verification under the applicant’s control or possession or written proof providing reasonable justification for the failure to comply. Nationwide denied Svetlana Epp’s claim for failure to provide the requested verification or written proof providing reasonable justification for the failure to comply within 120 calendar days after our initial request on September 30, 2020. Additionally, Sveltana Epp’s claim was also denied pursuant to 11 NYCRR 65-3.12(a)(1) and 11 NYCRR 65-3.12(10)(c). Therefore, based on the aforementioned, your claim for services is denied. If you have any questions regarding payment, please contact your insurance carrier. If you have questions regarding this Explanation of Review, please contact our Customer Service Department at 877-444-8763. PO BOX 26005, DAPHNE, AL 36526 877.444.8763 Printed On -- 01-Mar-2021 1:32 pm Page 4 of 5 FILED: ONONDAGA COUNTY CLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021 NYSCEF DOC. NO. 69464160-GK RECEIVED NYSCEF: 06/24/2022 Claim Number -- Total Charges --$ 2,315.50 QW0041338- EOBID -db Archive Copy Billing Provider -- ADVANT ORTHOCARE INC Total Reimbursement --$ 0.00 Service Provider -- ADVANT ORTHOCARE INC Patient Name -- EPPS, SVETLANA 07/11/2020 Dates Of Service -- - 07/11/2020 "If payment is due, check will be mailed under separate cover. Cashing this check will not forfeit your appeal rights. The amount shown should be considered full payment for service dates indicated, unless additional information is requested. WARNING: "ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS, OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION." APPEAL PROCESS: Please submit the following to the address listed below: 1. A copy of this Explanation of Reimbursement , 2. The reasons that you disagree with the reimbursement, 3. A copy of all supporting medical documentation concerning this appeal." If you have any questions regarding payment, please contact your insurance carrier. If you have questions regarding this Explanation of Review, please contact our Customer Service Department at 877-444-8763. PO BOX 26005, DAPHNE, AL 36526 877.444.8763 Printed On -- 01-Mar-2021 1:32 pm Page 5 of 5 FILED: ONONDAGA COUNTY CLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021 NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW NYSCEF DOC. NO. 69 RECEIVED NYSCEF: 06/24/2022 DENIAL OF CLAIM FORM TO INSURER: Complete this form, including item 33. Send two copies to applicant. Upon the request of the injured person, the insurer should send to the injured person a copy of all prescribed claim forms and documents submitted by or on behalf of the injured person. NAME, ADDRESS AND NAIC NATIONWIDE GENERAL INSURANCE COMPANY NUMBER OF INSURER OR PO BOX 26005 NAME AND ADDRESS OF For American Arbitration Association use SELF-INSURER DAPHNE, AL 36526 23760 Doc ID: QW0041338 A. POLICYHOLDER B. POLICY NUMBER C. DATE OF ACCIDENT D. INJURED PERSON JOHANN BENEDICT BARKER 6631J 066695 04/15/2020 Epps, Svetlana E. CLAIM NUMBER F. APPLICANT FOR BENEFITS (Name and address) 305 OCEAN PARKWAY APT 2K Advant Orthocare Inc BROOKLYN, NY 11218 464160-GK 5847 Francis Lewis BlvdSte 17 G. AS ASSIGNEE Bayside, NY 11364 1.Yes x 2.No o TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO CONTEST THIS DENIAL YOU ARE ADVISED THAT FOR REASONS NOTED BELOW: o 1. Your entire claim is denied as follows: x 2. A portion of your claim is denied as follows: o A. Loss of Earnings: $ o D. Interest: $ x B. Health Service Benefits: $ 2315.50o E. Attorney's Fees: $ o C. Other Necessary Expenses: $ o F. Death Benefit: $ REASON(S) FOR DENIAL OF CLAIM (Check reasons and explain below in item 33) POLICY ISSUES o 3. Policy not in force on date of accident o 6. Injured person not an "Eligible Injured Person" o 4. Injured person excluded under policy conditions or exclusion o 5. Policy conditions violated: o 7. Injuries did not arise out of use or operation of a motor vehicle o a. No reasonable justification given for late notice of claim. o 8. Claim not within the scope of your election under o b. Reasonable justification not established. You may qualify for special Optional Basic Economic Loss coverage expedited arbitration. See page 2 of this form for instructions. LOSS OF EARNINGS BENEFITS DENIED o 9. Period of disability contested: period in dispute o 11. Exaggerated earnings claim of $ per month denied From Through o 12. Statutory offset taken o 10. Claimed loss not proven o 13. Other, explained below: OTHER REASONABLE AND NECESSARY EXPENSES DENIED o 14. Amount of claim exceeds daily limit of coverage o 16. Incurred after one year from date of accident o 15. Unreasonable or unnecessary expenses o 17. Other, explained below HEALTH SERVICE BENEFITS DENIED o 20. Treatment not related to accident x 18. Fees not in accordance with fee schedules o 21. Unnecessary treatment, service or hospitalization o 19. Excessive treatment, service or hospitalization From Through From Through x 22. Other, explained below: COMPLETE ITEMS 23 THROUGH 32 IF CLAIM FOR HEALTH SERVICE BENEFITS IS DENIED 23. Provider of Health Service (Name, Address and Zip Code) 25. Period of bill-treatment dates 28. Date final verification requested 31. Amount paid by insurer ADVANT ORTHOCARE INC 07/11/2020 - 07/11/2020 10/08/2020 5847 Francis Lewis BLVD STE 17 26. Date of bill 29. Date final verification received 32. Amount in dispute Bayside, NY 11364 08/10/2020 24. Type of service rendered 27. Date received by insurer 30. Amount of bill 2315.50 Medical 08/20/2020 2315.50 SEE ATTACHED EOR FOR EXPLANATION OF REDUCTION 33. State reason for denial, fully and explicitly (attach extra sheets if needed): See the attached explanation of review for docid PUPILJ1 - JENNIFER PUPILLO QW0041338 Name, and Title of Representative of Insurer DATE 03/01/2021 PO BOX 26005 TELEPHONE NUMBER: 315.453.3476 EXT. DAPHNE, AL 36526 Name and address of Insurer claim processor (Third Party Administrator), if applicable NYS FORM NF-10 (Rev 1/2017) Page 1 of 4 FILED: ONONDAGA COUNTY CLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021 NYSCEF DOC. NO. 69 DENIAL OF CLAIM FORM - PAGE TWO RECEIVED NYSCEF: 06/24/2022 IF YOU WISH TO CONTEST THIS DENIAL, YOU HAVE THE FOLLOWING OPTIONS: 1. Should you wish to take this matter up with the New York State Department of Financial Services, you may file with the Department either on its website at http://www.dfs.ny.gov/consumer/fileacomplaint.htm or you may write to or visit the Consumer Assistance Unit, Financial Frauds and Consumer Protection Division, New York State Department of Financial Services, at: One State Street, New York, NY 10004; One Commerce Plaza, Albany, NY 12257; 1399 Franklin Avenue, Garden City, NY 11530, or Walter J. Mahoney Office Building, 65 Court Street, Buffalo, NY 14202. Although the Department of Financial Services will attempt to resolve disputed claims, it cannot order or require an insurer to pay a disputed claim. If you wish to file a written complaint, send one copy of this Denial of Claim Form with copies of other pertinent documents with a letter fully explaining your complaint to the Department of Financial Services at one of the above addresses. If you choose this option, you may at a later date still submit this dispute to arbitration or bring a lawsuit; or 2. You may submit this dispute to arbitration. If you wish to submit this claim to arbitration, then mail or e-mail a copy of this Denial of Claim Form along with a complete submission of all other pertinent documents and a table of contents listing your submissions, in duplicate together with a $40 filing fee, payable by check, money order, or credit card to the American Arbitration Association (AAA) to: AMERICAN ARBITRATION ASSOCIATION (AAA) NEW YORK INSURANCE CASE MANAGEMENT CENTER 120 BROADWAY NEW YORK, NEW YORK 10271 nyicmc.filingsubmissions@adr.org Please contact the American Arbitration Association's customer service department at (917) 438-1660 with any questions about case filing. A complete copy of this filing, listing all bills and proofs as well as a table of contents listing your submissions must be provided to the AAA and the insurer at the time of filing for arbitration. The filing must be complete with all necessary documentation, as any late submission may not be admissible at arbitration. The filing fee will be returned to you if the arbitrator awards you any portion of your claim. However, you may be assessed the costs of the arbitration proceeding if the arbitrator finds your claim to be frivolous, without factual or legal merit or was filed for the purpose of harassing the respondent. The decision of an arbitrator is binding, except for limited grounds for review set forth in the Law and regulations promulgated thereunder. If you are contesting the denial of claim and wish to submit the dispute to arbitration, state on accompanying sheets the reason(s) you believe the denied or overdue benefits should be paid. Attach proof of disability and verification of loss of earnings in dispute, sign below, and send the completed form to the American Arbitration Association at the address given in item 2 above. Loss of Earning : Date claim made:_____________________ Gross Earning per month $_______________________ ___________Through____________ Amount Claimed : $_____________________________ Period of dispute: From Health Service: (Attach bills in dispute and list each one separately) Name of Provider Date of Service Amount of Bill Amount in Dispute Date Claim Mailed Other Necessary Expense : (Attach bills in dispute and list each one separately) Type of Expense Claimed Amount Claimed Date Incurred Date Claim Mailed Amount in Dispute Other: (attach additional sheet if necessary) i Upon your request, if you file for arbitration within 90 days of the date of this denial or the claim becoming overdue, your case will be scheduled for arbitration on a priority basis. i You qualify for special expedited arbitration if the insurer has determined that your written justification for submitting late notice of claim failed to meet a "reasonableness standard". Your specific request for special expedited arbitration must be filed within 30 days of the date of denial. Your filing must be complete and contain all information that you are submitting at the time of filing. NYS FORM NF-10 (Rev 1/2017) Page 2 of 4 FILED: ONONDAGA COUNTY CLERK 06/24/2022 02:55 PM INDEX NO. 007351/2021 NYSCEF DOC. NO. 69 RECEIVED NYSCEF: 06/24/2022 DENIAL OF CLAIM FORM - PAGE THREE 3. You may bring a lawsuit to recover the amount of benefits you claim to be entitled to. THE UNDERSIGNED AFFIRMS AND CERTIFIES AS TRUE UNDER THE PENALTY OF PERJURY THAT THIS FILING IS BEING MADE IN GOOD FAITH AND THAT UPON INFORMATION, BELIEF AND REASONABLE INQUIRY THE DOCUMENTS BEING SUBMITTED HEREWITH ARE NOT FRAUDULENT AND THAT EXACT COPIES OF ALL DOCUMENTS PROVIDED HEREWITH HAVE BEEN MAILED TO THE INSURER AGAINST WHOM THE ARBITRATION IS BEING REQUESTED. UNLESS DISCLOSED WITH THIS SUBMISSION, THE DISPUTED AMOUNTS REMAIN UNPAID TO THE APPLICANT BY ANY PAYOR AND THERE HAS BEEN NO OTHER FILING OF AN ARBITRATION REQUEST OR LAWSUIT TO RESOLVE THE DISPUTED MATTERS CONTAINED IN THIS SUBMISSION. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWI