FORMAL NOTICE OF ADVERSE BENEFIT DETERMINATION DISPUTE PURSUANT TO ERISA § 503 (29 U.S.C. § 1133) & 29 CFR § 2560.503-1 DATE: September 15, 2026 PACKET REFERENCE: APPEAL-ERISA-4AB404E2 CLAIM REFERENCE NUMBER: CLM-2026-NY-8912 PATIENT / MEMBER NAME: ELEANOR RIGBY PATIENT ID: UHC-98234109-01 HEALTHCARE PROVIDER: MEMORIAL REGIONAL HEALTH DATE OF SERVICE: 01/14/2026 ATTN: APPEALS & GRIEVANCE COMMITTEE / CLAIMS REVIEW DEPARTMENT Dear Claims Administrator, I am writing to formally dispute the adverse benefit determination and cost-sharing adjudication rendered on Claim #CLM-2026-NY-8912. A deterministic statutory audit of the line items against the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) PTP tables has identified improper unbundled charges and/or unlawful patient liability reassignments. TOTAL BILLED BY PROVIDER: $4,460.00 ADJUDICATED PATIENT RESPONSIBILITY: $542.00 TOTAL UNLAWFUL CHARGES EXCISED: $370.00 CORRECTED LAWFUL PATIENT LIABILITY: $172.00 DETAILED AUDIT FINDINGS & STATUTORY BASES: 1. [Line 2] Violation: NCCI_INDICATOR_0_UNBUNDLING Procedure Codes: 80053 / 80048 Disputed Amount: $190.00 Regulatory Authority: CMS NCCI Policy Manual, Chapter 1, Section A (PTP Indicator 0) Audit Finding: Illegal Unbundling: Secondary CPT 80048 is an integral component of primary CPT 80053. CMS PTP Indicator 0 strictly forbids separate billing under any circumstances. Rationale: HCPCS/CPT code definition includes component. 2. [Line 4] Violation: NCCI_INDICATOR_0_UNBUNDLING Procedure Codes: 99285 / 70450 Disputed Amount: $180.00 Regulatory Authority: CMS NCCI Policy Manual, Chapter 1, Section E (PTP Indicator 1) Audit Finding: Unbundled Procedure: CPT 70450 is mutually exclusive with CPT 99285 and lacked an appropriate CMS clinical modifier (Modifier 59/X-subset). 3. [Line 2] Violation: CARC_UNBUNDLED_BALANCE_SHIFT Procedure Codes: 80048 Disputed Amount: $190.00 Regulatory Authority: CMS Claims Processing Manual, Pub. 100-04, Chapter 23 § 20.9; ERISA § 503 (29 U.S.C. § 1133) Audit Finding: Predatory Balance Shift (CARC 97): Insurer correctly adjudicated CPT 80048 as an unbundled service included in primary procedure payment, but improperly shifted $190.00 to Patient Responsibility (PR). Remedy: Reallocate from Patient Responsibility (PR) to Contractual Obligation (CO). Under CMS guidelines and commercial in-network provider contracts, unbundled component services cannot be balance-billed to the patient. 4. [Line 2] Violation: CARC_UNBUNDLED_BALANCE_SHIFT Procedure Codes: 80048 Disputed Amount: $190.00 Regulatory Authority: CMS Claims Processing Manual, Pub. 100-04, Chapter 23 § 20.9; ERISA § 503 (29 U.S.C. § 1133) Audit Finding: Predatory Balance Shift (CARC 97): Insurer correctly adjudicated CPT 80048 as an unbundled service included in primary procedure payment, but improperly shifted $190.00 to Patient Responsibility (PR). Remedy: Reallocate from Patient Responsibility (PR) to Contractual Obligation (CO). Under CMS guidelines and commercial in-network provider contracts, unbundled component services cannot be balance-billed to the patient. DEMAND FOR RELIEF UNDER FEDERAL LAW: Pursuant to 29 CFR § 2560.503-1(h)(2)(iii), I hereby demand: 1. Immediate re-adjudication of Claim #CLM-2026-NY-8912 excising all unbundled and improperly shifted amounts totaling $370.00. 2. Immediate adjustment of provider billing to reflect that unbundled component services are Contractual Obligations (CO) of the participating provider and cannot be balance-billed to the member. 3. Complete disclosure of all internal claim protocols, fee crosswalks, and NCCI edit rationales relied upon in the initial adverse determination. Failure to re-adjudicate within statutory time limits (30 days for post-service claims under 29 CFR § 2560.503-1(i)(1)(i)) will constitute failure to provide a reasonable claims procedure, entitling the member to pursue all available remedies under Section 502(a) of ERISA. Sincerely, ELEANOR RIGBY (Member) Digital Signature Token: VERIFIED_HUMAN_SIGNATURE_TOKEN Generated by UNBUNDLE Autonomous EOB Sentinel (Strands Agents SDK + AWS Bedrock AgentCore)