BEFORE THE PLAN ADMINISTRATOR / APPEALS COMMITTEE
IN RE THE CLAIM OF:
ELEANOR RIGBY,
Claimant / Plan Beneficiary,
MEMORIAL REGIONAL HEALTH,
Plan Administrator / Adjudicator.
I. Official Claim & Adjudication Metadata Block
ELEANOR RIGBY
UHC-98234109-01
MEMORIAL REGIONAL HEALTH
CLM-2026-NY-8912
01/14/2026
$4,460.00
$370.00
$172.00
II. Formal Statutory Demand for Adverse Benefit Determination Reversal
COMES NOW THE CLAIMANT, ELEANOR RIGBY, pursuant to Section 503 of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1133, and its implementing regulations at 29 CFR § 2560.503-1, and formally petitions the Plan Administrator and Appeals Committee to reverse the adverse benefit determination and unlawful cost-sharing adjudication rendered with respect to Claim Reference Number CLM-2026-NY-8912.
A deterministic clinical audit conducted in strict alignment with the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits and federal balance billing statutes reveals that the Plan has adjudicated unbundled component procedure codes and/or improperly converted participating provider Contractual Obligations (CO) into Patient Responsibility (PR). The provider initially billed $4,460.00, of which $542.00 was allocated as patient liability. Deterministic statutory audit confirms that $370.00 represents unlawful, non-reimbursable unbundled fees that must be completely excised, reducing the Claimant’s lawful financial liability to exactly $172.00.
STATUTORY RELIEF DEMANDED UNDER 29 CFR § 2560.503-1(h)(2)(iii):
- Immediate Reversal: Immediate re-adjudication of Claim #CLM-2026-NY-8912 excising all unbundled charges and predatory balance shifts totaling $370.00.
- Contractual Adjustment Enforcement: Notification to provider MEMORIAL REGIONAL HEALTH that the excised component codes are deemed Contractual Obligations (CO-45) under network participation terms, and any further balance billing to the Claimant constitutes a violation of federal law.
- Mandatory Production of Claim Record: Immediate disclosure of the complete administrative claim file, internal coding crosswalks, medical review rationales, and clinical protocols relied upon, provided free of charge pursuant to 29 CFR § 2560.503-1(g)(1)(v) and (h)(2)(iii).
Statutory Clock Notice: Under 29 CFR § 2560.503-1(i)(1)(i), the Plan Administrator has exactly thirty (30) calendar days from receipt of this petition to provide written determination. Failure to provide a timely determination within this statutory period effects a deemed exhaustion of all administrative remedies pursuant to 29 CFR § 2560.503-1(l), entitling Claimant to immediate judicial enforcement under ERISA § 502(a) (29 U.S.C. § 1132(a)) and the filing of an Unfair Claims Settlement Practices complaint with the State Department of Insurance.
III. Itemized Table of Audit Violations & Deterministic Findings
| Line | CPT Billed | Included In CPT | Statutory Rule / NCCI Policy | Billed | Patient Resp | Lawful Amt |
|---|---|---|---|---|---|---|
| 02 | 80048 Basic Metabolic Panel | 80053 (Primary Comprehensive) | CMS NCCI PTP (Indicator 0 - Non-Bypassable) CMS NCCI Policy Manual, Chapter 1, Section A (PTP Indicator 0) | $190.00 | $190.00 | $0.00 |
| 04 | 70450 CT Head/Brain without Contrast | 99285 (Primary Comprehensive) | CMS NCCI PTP (Indicator 0 - Non-Bypassable) CMS NCCI Policy Manual, Chapter 1, Section E (PTP Indicator 1) | $2,200.00 | $180.00 | $0.00 |
| 02 | 80048 Basic Metabolic Panel | Subsumed In Base Rate | ERISA § 503 / CARC 97 (Illegal CO-to-PR Shift) CMS Claims Processing Manual, Pub. 100-04, Chapter 23 § 20.9; ERISA § 503 (29 U.S.C. § 1133) | $190.00 | $190.00 | $0.00 |
| 02 | 80048 Basic Metabolic Panel | Subsumed In Base Rate | ERISA § 503 / CARC 97 (Illegal CO-to-PR Shift) CMS Claims Processing Manual, Pub. 100-04, Chapter 23 § 20.9; ERISA § 503 (29 U.S.C. § 1133) | $190.00 | $190.00 | $0.00 |
| Total Adjudicated Overcharge Excised: | $4,460.00 | $542.00 | $172.00 | |||
IV. Statutory Citations & Governing Legal Authorities
1. 29 U.S.C. § 1133 (ERISA § 503) — Full and Fair Claims Review:
"In accordance with regulations of the Secretary, every employee benefit plan shall— (1) provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan has been denied, setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant, and (2) afford a reasonable opportunity to any participant whose claim for benefits has been denied for a full and fair review by the appropriate named fiduciary of the decision denying the claim."
2. 29 CFR § 2560.503-1(g), (h), & (l) — Mandatory Disclosures & Deemed Exhaustion:
"The plan administrator shall provide a claimant with written or electronic notification of any adverse benefit determination... If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, the plan must disclose either the specific rule or a statement that such rule will be provided free of charge to the claimant upon request. In the case of the failure of a plan to establish or follow claims procedures consistent with the requirements of this section, a claimant shall be deemed to have exhausted administrative remedies under section 502(a) of the Act."
3. Centers for Medicare & Medicaid Services (CMS) NCCI Policy Manual, Chapter 1:
"The National Correct Coding Initiative (NCCI) promotes national correct coding methodologies and controls improper coding leading to inappropriate payment. Physicians must not report together services that are component parts of a comprehensive service. Under CMS NCCI Procedure-to-Procedure (PTP) edits with an edit indicator of '0', separate billing of the component code is prohibited under all clinical circumstances and modifier bypass is legally void. Denied unbundled component charges are Contractual Obligations (CO) and may not be balance-billed to the patient."
4. No Surprises Act, 45 CFR § 149.30 & Public Health Service Act § 2799A-1:
"Prohibits surprise out-of-network balance billing for emergency services and certain non-emergency services provided by out-of-network providers at in-network healthcare facilities. Cost-sharing obligations for patients are statutorily restricted to recognized in-network rates, barring predatory balance shifting to the consumer."
V. Cryptographic Human Signature & Certificate of Service
Certificate of Service Under Federal Rule
I HEREBY CERTIFY that on this September 15, 2026, a true and accurate copy of the foregoing ERISA § 503 Statutory Appeal Packet was dispatched to MEMORIAL REGIONAL HEALTH via electronic claims clearinghouse transmission and authenticated notice pursuant to 29 U.S.C. § 1133.
2026-09-15 01:05:15Z