On June 28, 2023 a
Exhibit,Appendix
was filed
involving a dispute between
People Of The State Of New York, By Letitia James, Attorney General Of The State Of New York,
and
Abraham Operations Associates Llc Dba Beth Abraham Center For Rehabilitation And Nursing,
Aharon Lantzitsky,
Amir Abramchik,
Aron Gittleson,
Beth Rozenberg,
Bis Funding Capital Llc,
Centers For Care Llc Dba Centers Health Care,
Cfsc Downstate Llc,
Daryl Hagler,
David Greenberg,
Delaware Operations Associates Llc Dba Buffalo Center For Rehabilitation And Nursing,
Delaware Real Property Associates Llc,
Elliot Kahan,
Hollis Operating Co Llc Dba Holliswood Center For Rehabilitation And Healthcare,
Hollis Real Estate Co Llc,
Jeffrey Sicklick,
Jonathan Hagler,
Kenneth Rozenberg,
Leo Lerner,
Light Property Holdings Ii Associates Llc,
Mordechai Moti Hellman,
Reuven Kaufman,
Schnur Operations Associates Llc Dba Martine Center For Rehabilitation And Nursing,
Skilled Staffing Llc,
Sol Blumenfeld,
for Commercial - Other - Commercial Division
in the District Court of New York County.
Preview
iD: YORK OUN PK 06 DM INDEX NO. 451549/2023
NYSCEF BOC. NO. 618 RECEIVED NYSCEF: 06/28/2023
PETTIGREW EXHIBIT 182
D2 EW OD RW) DUN NK 06 DM INDEX NO. 451549/2023
NYSCEF DOC. NO. 618 RECEIVED NYSCEF: 06/28/2023
(1) ETIN 870 (2) BILLING SERVICE NAME (IF APPLICABLE) |
eMedNY/MEDICAID MANAGEMENT INFORMATION SYSTEM
CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID
0820/2021
(3) As of (date) all claims submitted electronically or on paper to the Stale's Medicaid fiscal agent, for services or supplies furnished
(4) by (provider name) HOLLIS OPERATING CO LLC (5) (10-digit National Provider
ID (NPI) - REQUIRED unless
exempted from NPI)
1366782534
(6) (8-digit Medicaid Provider
Number -- If NPI exempt} 00308769
will be subject to the following certification.
| am {or the business entity named in this form of which | am a partner, officer, or director is} a qualified provider enrolled with and authorized to
anticipate in the New York Stale Medical Assistance Program and in the profession or specialties, if any, required in connection with this claim, the
persons providing services, care and suppties have the necessary iicensing, certification, training and experience to perform the claimed servi
have reviewed these claims: | (or the entity) have furnished or caused to be fumished the care. services, and supplies itemized and done s« in
accordance wilh applicabie federal and stale laws and regulations; ! have read the eMedNY Provider Manuat and all revisions thereto; all claims are
made in full complance with the pertinent provisions of the Manual and revisions; all ciaims for care, services and supplies provided at the order of
another professional have to the best of my knowledge been ordered by that orofessianal in bona fide compliance with the oracedures set forth in the
manual and revisions. All care, services and supplies for which claim is made are medically necessary for the treatment of the named recipient, the
amounls listed are due and, except as noted, no part thereof has been paid by, or to the best of my knowledge is payable from any cther source other
than the Medical Assistance Program; payment of fees made in accordance with established schedules is accepted as payment in full: other than a
claim rejected or denied or one for adjustment, no previous claim for the care, services and supplies itemized has been submitied or paid: ALL
STATEMENTS, DATA AND INFORMATION TRANSMITTED ARE TRUE, ACCURATE ANO COMPLETE TO THE BEST OF MY KNOWLEDGE; NO
MATERIAL FACT HAS BEEN OMITTED: I UNDERSTAND THAT PAYMENT AND SATISFACTION OF THIS CLAIM WILL 8E FROM FEDERAL,
STATE AND LOCAL PUBLIC FUNDS AND THAT | MAY BE FINEO AND/OR PROSECUTED UNDER APPLICABLE FEDERAL AND STATE LAWS
FOR ANY VICLATION OF THE TERMS OF THIS CERTIFICATION, INCLUDING BUT NOT LIMITED TO FALSE CLAIMS, STATEMENTS OR.
DOCUMENTS, OR CONCEALMENT OF A MATERIAL FACT; taxes from which the State is exempt are excluded; all records pertaining to the care,
services and supplies provided including all records which are necessary to disclose fully the extent of care, services and supplies provided to
individuals under the New York State Medical Assistance Program will be kept for a period of six years [rom the date of payment, and such records and
information regarding these claims and payment therefor shall be promptly furnished upon request to the toca! Department of Social Services, the State
Department of Health, the Olfice of the Medicaid Inspector General. the State Medicaid Fraud Control Unit or the Secretary of the Department of Health,
‘and Human Services: there has been compliance with the Faderai Civil Rights Aci of 1964 and with section 504 of he Federal Rehabililation Act of
1973, as amended, which forbid discrimination on the basis of race, color, national origin, handicap, age, Sex and religion; | agree (or tha entity agrees)
to comply with the requiremont of 42 CFR Pan 455 relaling to disclosures by providers: | (or ine entity) have adopted and implemented, where
applicable, an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title
48 of the New York Codes, Rules and Regulations Part $21; the State of New York through its fiscal agent ar otherwise is hereby authorized to (4) make
administrative corrections to claims submitted under this agreement to enable ils automated processing, subject to reversal by the provider, and (2)
accept the claim under this agreement as original evidence of care, services and supplies furnished.
In submitting claims under this agreement | understand and agree that | (or the entity) shall be subject to and bound by all rules, regulations, policies,
standards, fee codes and procedures of the New York State Oepartment of Health and the Office of the Medicaid Inspector General as sel forth in
statute oF title 18 of the Official Compilation of Codes, Rules and Regulation of New York Slate and other publications of the Department, including
@MedNY Provider Manuals and other official bulletins of the Department. | understand and agree that | (or the entity} shall be subject to and shall
‘accept, subject to due process of the law, any determinations pursuant te said rules, regulations, policies, standards, fee codes and procedures,
including, but not limited to, any duly made determination affecting my (or my entity's) past, present or fulure status in the Medicaid program and/or
imposing any duly cor idered sanction or penalty.
| UNDERSTAND THAT MY SIGNATURE HEREON THE SROVE CERTIFICATION WILL
APPLY TO ALL. CLAIMS SUBMITTED ELECTRONICAL! LY OR RyU: PLEASE DO NOT|
THI NTITY' NPI oR E ICID PROVIDER IDENTIFICATION NUM KS STAPLE OR
CERTIFICATIO! RE IN EFFE! CLAIMS" UNTIL
WRITE IN BAR
SUPERSEDED BY ANOTHER PROPERLY, EXECUTED CERTIFICATION STATEMENT.
CODE AREA
(7) éSignature) >: GYR (8) (Cate) 08/20/2021
(9) (Print Name and Title) SHIA DEUTSCH, CONTROLLER
(10) (Telephone #}
718-931-9700X 112 (11) (eMail, if avai itable) SHia@centersbusiness.org
ry Public
stare or New York Menachem Orzet
COUNTY OF Bronx, (12) 1D: 010R6365302
County: Rockland
On this 20th day of August 2021 , vetore me personally came Expires; 10/02/2021
Shia Deutsch to me know and knewn to me _{o the individual describedin and whe
execuled the foregoing instrument, and (s)he acknowledge, (s)he executed tf Sfime.
(SEAL)
Se
NOTARM BUBLIG——
EMEDNY-490601 (10/20)
Preview
iD: YORK OUN PK 06 DM INDEX NO. 451549/2023 NYSCEF BOC. NO. 618 RECEIVED NYSCEF: 06/28/2023 PETTIGREW EXHIBIT 182 D2 EW OD RW) DUN NK 06 DM INDEX NO. 451549/2023 NYSCEF DOC. NO. 618 RECEIVED NYSCEF: 06/28/2023 (1) ETIN 870 (2) BILLING SERVICE NAME (IF APPLICABLE) | eMedNY/MEDICAID MANAGEMENT INFORMATION SYSTEM CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID 0820/2021 (3) As of (date) all claims submitted electronically or on paper to the Stale's Medicaid fiscal agent, for services or supplies furnished (4) by (provider name) HOLLIS OPERATING CO LLC (5) (10-digit National Provider ID (NPI) - REQUIRED unless exempted from NPI) 1366782534 (6) (8-digit Medicaid Provider Number -- If NPI exempt} 00308769 will be subject to the following certification. | am {or the business entity named in this form of which | am a partner, officer, or director is} a qualified provider enrolled with and authorized to anticipate in the New York Stale Medical Assistance Program and in the profession or specialties, if any, required in connection with this claim, the persons providing services, care and suppties have the necessary iicensing, certification, training and experience to perform the claimed servi have reviewed these claims: | (or the entity) have furnished or caused to be fumished the care. services, and supplies itemized and done s« in accordance wilh applicabie federal and stale laws and regulations; ! have read the eMedNY Provider Manuat and all revisions thereto; all claims are made in full complance with the pertinent provisions of the Manual and revisions; all ciaims for care, services and supplies provided at the order of another professional have to the best of my knowledge been ordered by that orofessianal in bona fide compliance with the oracedures set forth in the manual and revisions. All care, services and supplies for which claim is made are medically necessary for the treatment of the named recipient, the amounls listed are due and, except as noted, no part thereof has been paid by, or to the best of my knowledge is payable from any cther source other than the Medical Assistance Program; payment of fees made in accordance with established schedules is accepted as payment in full: other than a claim rejected or denied or one for adjustment, no previous claim for the care, services and supplies itemized has been submitied or paid: ALL STATEMENTS, DATA AND INFORMATION TRANSMITTED ARE TRUE, ACCURATE ANO COMPLETE TO THE BEST OF MY KNOWLEDGE; NO MATERIAL FACT HAS BEEN OMITTED: I UNDERSTAND THAT PAYMENT AND SATISFACTION OF THIS CLAIM WILL 8E FROM FEDERAL, STATE AND LOCAL PUBLIC FUNDS AND THAT | MAY BE FINEO AND/OR PROSECUTED UNDER APPLICABLE FEDERAL AND STATE LAWS FOR ANY VICLATION OF THE TERMS OF THIS CERTIFICATION, INCLUDING BUT NOT LIMITED TO FALSE CLAIMS, STATEMENTS OR. DOCUMENTS, OR CONCEALMENT OF A MATERIAL FACT; taxes from which the State is exempt are excluded; all records pertaining to the care, services and supplies provided including all records which are necessary to disclose fully the extent of care, services and supplies provided to individuals under the New York State Medical Assistance Program will be kept for a period of six years [rom the date of payment, and such records and information regarding these claims and payment therefor shall be promptly furnished upon request to the toca! Department of Social Services, the State Department of Health, the Olfice of the Medicaid Inspector General. the State Medicaid Fraud Control Unit or the Secretary of the Department of Health, ‘and Human Services: there has been compliance with the Faderai Civil Rights Aci of 1964 and with section 504 of he Federal Rehabililation Act of 1973, as amended, which forbid discrimination on the basis of race, color, national origin, handicap, age, Sex and religion; | agree (or tha entity agrees) to comply with the requiremont of 42 CFR Pan 455 relaling to disclosures by providers: | (or ine entity) have adopted and implemented, where applicable, an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 48 of the New York Codes, Rules and Regulations Part $21; the State of New York through its fiscal agent ar otherwise is hereby authorized to (4) make administrative corrections to claims submitted under this agreement to enable ils automated processing, subject to reversal by the provider, and (2) accept the claim under this agreement as original evidence of care, services and supplies furnished. In submitting claims under this agreement | understand and agree that | (or the entity) shall be subject to and bound by all rules, regulations, policies, standards, fee codes and procedures of the New York State Oepartment of Health and the Office of the Medicaid Inspector General as sel forth in statute oF title 18 of the Official Compilation of Codes, Rules and Regulation of New York Slate and other publications of the Department, including @MedNY Provider Manuals and other official bulletins of the Department. | understand and agree that | (or the entity} shall be subject to and shall ‘accept, subject to due process of the law, any determinations pursuant te said rules, regulations, policies, standards, fee codes and procedures, including, but not limited to, any duly made determination affecting my (or my entity's) past, present or fulure status in the Medicaid program and/or imposing any duly cor idered sanction or penalty. | UNDERSTAND THAT MY SIGNATURE HEREON THE SROVE CERTIFICATION WILL APPLY TO ALL. CLAIMS SUBMITTED ELECTRONICAL! LY OR RyU: PLEASE DO NOT| THI NTITY' NPI oR E ICID PROVIDER IDENTIFICATION NUM KS STAPLE OR CERTIFICATIO! RE IN EFFE! CLAIMS" UNTIL WRITE IN BAR SUPERSEDED BY ANOTHER PROPERLY, EXECUTED CERTIFICATION STATEMENT. CODE AREA (7) éSignature) >: GYR (8) (Cate) 08/20/2021 (9) (Print Name and Title) SHIA DEUTSCH, CONTROLLER (10) (Telephone #} 718-931-9700X 112 (11) (eMail, if avai itable) SHia@centersbusiness.org ry Public stare or New York Menachem Orzet COUNTY OF Bronx, (12) 1D: 010R6365302 County: Rockland On this 20th day of August 2021 , vetore me personally came Expires; 10/02/2021 Shia Deutsch to me know and knewn to me _{o the individual describedin and whe execuled the foregoing instrument, and (s)he acknowledge, (s)he executed tf Sfime. (SEAL) Se NOTARM BUBLIG—— EMEDNY-490601 (10/20)