SStateFarm’ EXPLANATION OF REVIEW ‘This nota Claim Number: 59-64R9-451. Date of Loss: 08-16-2023 Office Name: State Farm Fire And Casuelly Company PIPMPC AM FL DED Office Patient: Jessica R Joline Provider: Joseph Spine Pa clo Neiska Law Group 1840 MEASE DR STE 309 1914 E LAS OLAS BLVD PMB 2358 ‘SAFETY HARBOR, FL 34695-6805 FT LAUDERDALE, FL 33301-2334 Claim Handler: Yovanna Rosario Named Ineured: JOLINE, JESSICA R ‘Address: PO Box 106134 . Policy Number: L541-553-59 : : 7 ‘Avianta, GA 30248-6124 ee heat Phone: (844)202-8615 Ext: 8633184351 Date Recelved: 12-01-2623 Jurisdiction: Florida Bill Referonce Number: 2228600 Diagnosis Cades: M47.812 - Spondyiosis without myelopathy or radiculopathy, cervical region [M60.90 - Cervical disc disorder, unspecified, unspacified cervical region = Raticulopaty,cendeaLeegion - ‘S13.9XXA - Sprain of joints and ligaments of unspecited parts of neck, hiial encounter cpt ‘Submitted Approved Line Detect Service Pos HCPCS Moprrs Unit, "Amount" Amauint Reason Codes, 1 terest 99203 100 $1,132.00, $0.00 x202 Total Submitted Charges: $1,492.00 3 $0.00 ” + $6.00 : . $0.00 : : ; $0.00 : Apportionment /Pro Rata: $0.00 . : Offset $0.00 ; Paid Amount: $0.09 Explanations X202- Policy benefits have been exhausted. Procedure Guide {98203 - Office or other outpatient visit forthe evaluation and management cf a new patient, which requires a medically appropriate history and/or examination and low level af medical decision making. When using tite for code selection, 30-44 minutes of total time is spent on the date of the encounter. Pursuant to Florida Statute, should you have any information fo substantiate payment of an additional amount {or the services rendered, please forward for our consideration within 15 days. ‘Any person who knowingly and with intent to injure, defraud, or decelve any Insurance company, files a stalement of claim containing false, incomplete, or misleading information is guilty ofa felony of the third degree. F.S. 817.234(1)(b). DATE: 12-08-2023 ‘59-54R9-45L Professional soon ore verea 22 ovateInformation on administering benefits under the 9810A policy form: Effective forall claims with a reported date of loss 10/04/2017 or later, the Emergency Medical Condition provisions of the Florida No-Fault statute are being applied. Please contact us if you have any questions. DATE: 12.05.2023 59-54R9-451. Professional 08078 ora verge 292 nota