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Ball, Lucille D - 5/15/1984 MRN 7815-5709

Female · 36y 7mo · $125 balance · 3 open bills · 2 open claims
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ALERT: Significant allergic reaction to penicillin noted during last visit. Please verify medication before proceeding.
Demographics
Lucille Désirée Ball
  • 1000 North Roxbury Drive
    Beverly Hills, CA  90210
  • 5/15/1984 (36y 7m)
  • XXX–XX–6789
Code 95
APG
No therapy
Wheelchair required
Contact
Patient Balance
Type Amount Due
0-30 days 31-60 days 61-90 days 91-120 days 120+ days Total
Patient 3600 10075 13675
Insurance 24000 24000
Total 3600 10075 24000 37675
Insurance
Plan Policy # Effective Owner (Relation) Authorizations Copays
Empire Blue Cross Blue Shield of New York IWAAN8358571 5/3/2021 Lucille Ball (Self)
OT Auth Ahava
3/13 Remaining

PT Auth Ahava
0/10 Remaining
 $15 - PCP
$25 - Specialist
$75 - Urgent Care
Medicare 1EB6-YY4-NZ11 7/1/2021 Lucille Ball (Self) $25 - PCP
Medicaid QR62052S 7/1/2021 Lucille Ball (Self) -NO COPAY-
Comments
Type Date Comment Author
Bill 10/18/21 3:35p Spoke with HealthFirst, delay 1 week. Ref# 938-188873
938-188873.pdf 		Menashe Rottenberg
Patient 10/12/21 11:29a Patient will pay co-pay at next visit Chavi Goldwasser
Patient 7/22/21 9:54a Authorization only valid for 99211-99214 Yekutiel Bassul
Upcoming Appointments
Date Provider Office Visit Type Duration Pay Schedule Notes
12/18/2021 @2:45p Khelemsky, Igor Ahava Williamsburg Neurology 30m Default
12/11/2021 @11:30a Carrey, Zev Ahava Williamsburg P.T. 30m Default
Bills/Claims
Svc Date Bill ID Svc Prov Tr Office Charge Last Updated Status Adjust Paid Bal
8/17/2021 b6789 Zhivago, Yuri Ahava Monsey $47500 Not Submitted
8/1/2021 b3456 Kantor, Yevgeniy Ahava Monsey $47500 8/25/2021 In Queue $10750 $8350 $800
8/1/2021 b1234 Carrey, Zev Ahava Monsey $47500 8/25/2021 Completed $27965 $19925 $1200
Recent Visits
Date Provider Office Visit Type (Duration) Pay Schedule Status Bill Notes
11/5/2021 @2:00p Gomez, Olga Ahava Monsey O.T. (60m) Workman's Comp In 1:58p / Out 2:29p; 31m b333
Diagnoses
Last Used Description
8/18/2019 E55.9 Vitamin D Deficiency
8/18/2019 Z63.1 Problems in relationship with in-laws
8/10/2019 V00.01XD Pedestrian on foot injured in collision with roller-skater, subsequent encounter
Procedures
Last Used Description
10/18/2021 99212 Office or other outpatient visit for the evaluation and management of an established patient
8/18/2019 J7321 Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose
8/10/2019 20611 Arthrocentesis, aspiration and/or injection
Demographics
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Flags
Billing
Special Needs
PCP/Referrers

PCP

Dr. Gregory House
Internist – (609) 853-7000
–

RFR

Dr. Yuri Zhivago
Cardiologist – (212) 523-7570
–
RFR
Dr. Clifford Huxtable
OB/GYN – (212) 305-2500
–
Contact Methods
Home (212) 555-1212 Emergency
call after 6pm
Cell (917) 123-4567 Preferred
Email [email protected]
Other Info
Family Members
family-photo
Dezi Rodrigo Arnaz
Male – Nov 15, 1979 – 42y
family-photo
Little Ricky
Male – May 1, 2009 – 11y 6m
Contact Methosds
Add contact method
Type Value Comment
Preferred
General

Diagnoses

W55.41XA
Bitten by pig, initial encounter​
Z63.1
Problems in relationship with in-laws
V91.07XD
Burn due to water-skis on fire, subsequent encounter
V00.01XD
Pedestrian on foot injured in collision with roller-skater, subsequent encounter

Service Lines
Procedure - Modifiers Units Diagnoses Charge Paid Balance
99212
–
25
–
59
Office or other outpatient visit for the evaluation and management of an established patient
1 W55.41XA
Z63.1
V00.01XD 		$250 $0
J7321
–
TS
Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose
1 Z63.1
V00.01XD 		$200 $0
20611
Arthrocentesis, aspiration and/or injection
1 V91.07XD $300 $300
Attachments

Current Attachments
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Referring Provider - HCFA Only
Svc Date Bill ID Svc Provider Tr. Office Charge Claim Date Claim ID Payer Adjust Paid Bal
8/1/2021 b1234 Carrey, Zev Ahava Monsey $47500 8/5/2021 c333 H Blue Cross $9865 $13875 $23760
8/1/2021 b1234 Carrey, Zev Ahava Monsey 8/12/2021 c444 H Medicare $18000 $1600 $5760
8/1/2021 b1234 Carrey, Zev Ahava Monsey 8/25/2021 c555 2 U Medicaid $110 $4450 $1200
$27965 $19925 $1200
8/1/2021 b4321 Kantor, Yevgeniy Ahava Monsey $19800 8/3/2021 c222 H Blue Cross $9800 $5000 $5000
8/1/2021 b4321 Kantor, Yevgeniy Ahava Monsey 8/25/2021 c555 2 U Medicaid $950 $3350 $800
$10750 $8350 $800
8/17/2021 b3456 Zhivago, Yuri Ahava Monsey $25500 8/21/2021 c666 U Medicaid Awaiting response
9/3/2021 b6789 Carrey, Zev Ahava Monsey Not Submitted
Date Provider Office Visit Type Duration Incident Status Bill Notes
12/18/2021 @2:45p Khelemsky, Igor Ahava Williamsburg Neurology 30m Default Future
12/11/2021 @11:30a Carrey, Zev Ahava Williamsburg P.T. 30m Default Future
11/5/2021 @2:00p Gomez, Olga Ahava Monsey O.T. 60m Workman's Comp In 1:58p / Out 2:29p; 31m b333
9/7/2021 @2:00p Carrey, Zev Ahava Monsey P.T. 30m Default Reschedule Will call next week to set new time
Name Su Mo Tu We Th Fr Sa Start End
BBDO
Sterling Cooper
Insurance Plans
Insurance Eligibility (view history)
Commercial
H Empire Blue Cross Blue Shield of New York Aetna
IWAAN8358571
TT282827871
1EG4-TE5-MK72
9F88-JJ6-PZ99
(Self)
2/2/2022
4/2/2019
Overrides:
Arnaz
Male
5010 Main Street
12287
Copays:
PCP
$15
Specialist
$25
Urgent Care
$75
Scan Card Images
Result date:
9/16/2021
Result:
Active Policy Primary
Payer (ID):
EMPIRE (00044)
Plan Date:
7/1/2020
Plan Type:
DIRECT POS
Deductible left:
$49.85
Warning:
GRACE PERIOD
Medicare
H Medicare
1EB6-YY4-NZ11
(Self)
7/1/2021
Overrides:
Copays:
PCP
$25
Scan Card Images
Result date:
9/7/2021
Result:
Active Policy Secondary
Payer (ID):
CMS (00431)
Plan Date:
7/1/2020
Plan Type
Medicare Part B
Deductible left:
$507.22
Medicaid
U Medicaid
QR62052S
Desi Arnaz
7/1/2021
Overrides:
5/15/1985
Copays:
-NO COPAY-
Scan Card Images
Result date:
-
Result:
Unknown
Payer Schedules (Cases)
Default Schedule
  1. Empire Blue Cross Blue Shield of New York
  2. Medicare
  3. Medicaid
Workmans Comp Note Required
  1. Empire Blue Cross Blue Shield of New York
  2. Medicare
Mental Health
Applies to all psych visits
  1. Medicaid
Authorizations
Occupational Therapy Approved
Empire Blue Cross Blue Shield of New York
Effective: 7/2/2021 - 12/28/2021
Auth #: 08Q5T504R
Visits: 3/13 Remaining
Description: OT Auth Ahava
Payer Schedule: Workmans Comp
Physical Therapy Depleted
Empire Blue Cross Blue Shield of New York
Effective: 5/4/2021 - 12/21/2021
Auth #: 17V5T338P
Visits: 0/10 Remaining
Description: PT Auth Ahava
Payer Schedule: Default Schedule
Provider: Dr. Victor Frankenstein
Billable ICDs: M62.1 M25.512
Billable CPTs: 97110

Total Charges

$475.00

Total Payments

$199.75

Open Balance

$12.00
Date Details Ref Debit Credit Writeoff Balance
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