Sudhir M. Parikh Date: 10/15/2012
617 79th St Patient Name: Magaly Cid
North Bergen, NJ 07047 Insured’s Id# 700003273000

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Claim# 0112271166305

Adm/ Svc Date: 11/19/2011

Dear Provider/Billing Manager:

We have concluded our investigation of the attached inquiry requesting status information and have determined that:

❑ Claim was approved on____________________ in the amount of $___________________ on check#. ❑ Other ______________________________________________________ ❑ Claim was denied on ____________ because: ❑ Service(s) were not authorized ❑ No clinical review was provided ❑ Continued stay not medically necessary ❑ Late submission √ Other: ____maximum paid by other carrier__________ ❑ The patient is not enrolled under the name or identification number you provided. ❑ We have no record of receiving a claim based upon the information provided, please submit a completed UB-92 or HCFA-1500 claim form as appropriate to:
HealthFirst, Inc.
PO Box 5196
New York, NY 10274-5196.
(888) 801-1660
All requests for review or reconsideration must be submitted within sixty (60) days of the receipt date of the explanation of payment (EOP). Failure to submit a request for review or reconsideration within sixty (60) days, will result in the denial of your request. Please note that HealthFirst does not accept computer printouts/ledgers as proof of timely filing.

Please note that since this is a HealthFirst Managed Care member, the member is not to be billed, balanced billed, or held liable for any treatment rendered by participating providers.

Sincerely, Claims Department

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LTR/ Status Request/ All LOB

HealthFirst accepts claims electronically. For more information, call 1-888-801-1660 or e-mail: eclaims@healthfirst.org