HomeMy WebLinkAbout233765 06/18/14 0\ CITY OF CARMEL, INDIANA VENDOR: 368319
I ONE CIVIC SQUARE JENNIFER HUTSON CHECK AMOUNT: $*******398.12*
:9 j?� CARMEL, INDIANA 46032 1594 WHITE ASH DR CHECK NUMBER: 233765
.y,«oN��. CARMEL IN 46033 CHECK DATE: 06/18/14
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102. 5023990 398.12 OTHER EXPENSES
ARIVIEL
JA,viEs BRAINARD, MAYOR
June 16, 2014
Jennifer Hutson
1594 White Ash Drive
Carmel, IN 46033
RE: Ticket#20141398:1 D.O.S. 03/20/2014
Dear Jennifer Hutson:
Enclosed you will find a reimbursement check in the amount of$ 398.12.
On May 06, 2014 we received your payment for$497.65 paid the account in full.
Allied Benefit System reprocessed your claim paid$ 398.12 on May 08,2014 the patient
responsibility amount is now$ 99.53.
The overpayment$ 398.12 is enclosed.
If you have any questions, please feel free to contact me at(3 17) 571-2604.
Sincerely,
Michelle T. Harrington
Billing Administrator
CARMEL FIRE DEPARTMENT
STEVEN A. CouTs HEADQUARTERS
Two Cmc SQUARE, CARMEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615
r CARMEL FIRE DEPARTMENT
2 CIVIC SQUARE
CARMEL, IN 46032-7543
z" (317) 571 2604 Federal ID#356000972
Patient Name: HUTSON,JENNIFER E
JENNIFER HUTSON CARMEL FIRE DEPARTMENT
1594 WHITE ASH DR 2 CIVIC SQUARE
CARMEL, IN 46033 CARMEL, IN 46032-7543
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID AMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 06/16/14 201000362
Ticket# : 20141398:1
Date of Service: 3/20/2014
DETACH HERE
REFUND $ 398.12 ALLIED BENEFIT SYSTEM REPROCESSED THE CLAIM.
i
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE $0.00
Pay online at www.govpaynet.com with PLC#7487 Run Number 20141398:1
Online Payment will charge a service fee.
Date of�SennceDescription ,Patient Name :' x`: Y Charges) Date tPayment(s)
Charges
3/20/2014 "ADVANCED LIFE HUTSON, JENNIFER E $475.00
3/20/2014 *MILEAGE HUTSON, JENNIFER E $22.65
---------------------------------
Charge Total: $497.65
Payments
Paid By: Invoice 03/20/14 $497.65
Paid By: HUTSON, JENNIFER E Payment 05/06/14 ($497.65)
Paid By: SAGAMORE HEALTH COMMERCIAL INSURANCE 05/09/14 ($398.12)
Paid By: HUTSON, JENNIFER E REFUND 06/16/14 $398.12
BALANCE $0.00
P209 71N1511 pl
Allied Benefit Systems, Inc. �
200 W. Adams, Suite 500 To Submit Claims Zlectro6'1�a'lly'
Chicago, IL 60606-5215 Please see MemY'ws1
Forwarding Service Requested For questions,ple'ose visit us at
www.alliedbeiierit.com
or contact us at(31 !)906-8080 or o
ALL FOR AADC 462 (800)288-2078(Oul fide of Illinois)
22074 0.7538 AB 0.403 _
11'I.I�I1i111�111111111111'Illllllllltllllnlllllulllllrr'111'1' Enrollee: JENNIFER HUTSON o
CARMEL FIRE DEPARTMENT 136 Patient: JENNII'E?lt IIA SON ^'
2 CIVIC SQUARE Patient#: 20141398 1 Z
CARMEL, IN 46032-2584
Claim #: 20703977-06 w
Group#: A14112
RECEIVED MAY Q8 214 Group: INDIANA 1-IEM0IPI(ILIA&"I'l-IROMB
Date: 05/01/2014
Explanation of Benefits for Services Provided By:CARMEL FIRE DEPARTMENT 2 CIVIC SQUARE CARINIEL IN 46032
Dates ofService Service Procedure Total Ineligible Reason Discount Covered By Deductible - C .-Pay I Ralance Paid Paymcnt
Code Code Charge Code Amount Plan Amount At iount I At Amount
03/20-03/20/2014 7 A0427 475.00 0.00 0.00 475,00 0.00 0.0 475.00 80%--- --390-.0(103/20-03/20/2014 7 A0425 22.65 0.00 0.00 22.65 0.00 0.0g 22.65 80% 18.1
TOTALS 497.651 0.001 0.00 497.65 0.00 0.Oq 497.65 398.12
Otl cr Credits or Adjustments
Total Net Payment 398.1
Paticut Responsibility 99.531
Service Code Description
7 AMBULANCE
Worksheet Comments
PAYMENT REFLECTS RECALCULATION OF ORIGINAL CLAIM.
20703977-01
*** This claim was processed per your Sagamore Plus contractual agreement.
F.OR SECURITY'PURPOSE9 THF:FACE OF.THIS bOCUMENT CONTAINS ® A$LUE'BACKGAOUh1D AN6 IVIG 3dP131N71Ff0i 1MTH aHC1FtDER'
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Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No.201(Rev.1995)
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and-;F have audited same in accordance
with IC 5-11-10-1.6.
_ 20
Clerk-Treasurer
VOUCHER NO. WARRANT NO.
\ ALLOWED 20
IN SUM OF $
ON ACCOUNT OF APPROPRIATION FOR
Board Members
Po#or INVOICE NO. ACCT#!TITLE AMOUNT
DEPT.# I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
a,
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund