HomeMy WebLinkAbout233811 06/18/14 (9,
CITY OF CARMEL, INDIANA VENDOR: 368324
ONE CIVIC SQUARE CATHERINE MIHAL CHECK AMOUNT: $*******395.10*CARMEL, INDIANA 46032 1259 BENTLEY WAY CHECK NUMBER: 233811
CARMEL IN 46032 CHECK DATE: 06118114
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 395.10 OTHER EXPENSES
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CITY ' �F X.
JANIEs BRAIv_ARD, MAYOR
June 16, 2014
Catherine Mihal
1259 Bentley Way
Carmel, IN 46032
RE: Ticket# 20134754:1 D.O.S. 10/23/2013
Dear Catherine Mihal:
Enclosed you will find a reimbursement check in the amount of$ 395.10.
On November 14, 2013 we received your payment for $ 493.88 claim applied
to your deductible.
Key Benefit Administrators reprocessed your claim paid $ 395.10 on February 26, 2014
the patient responsibility amount is now $ 98.78.
The overpayment amount is $ 395.10.
If you have any questions, please feel free to contact me at (3)17) 571-2604.
Sincerely,
Michelle T. Harrington
Billing Administrator
CARMEL FIRE DEYART.IENT
STEVEN A. COUTs HEADQUARTERS
TWO Civic SQUARE. CARNIEL, IN 46032 OFFICE 317.571.2600, FA<1 317.771.2615
CARMEL FIRE DEPARTMENT
. 2 CIVIC SQUARE
CARMEL, IN 46032-7543
`11"° (317) 571 2604 Federal ID# 356000972
Patient Name: MIHAL, CATHERINE J
CATHERINE MIHAL CARMEL FIRE DEPARTMENT
1259 BENTLEY WAY 2 CIVIC SQUARE
CARMEL, IN 46032 CARMEL, IN 46032-7543
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID AMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 06/16/14 201102929
Ticket# : 20134754:1
Date of Service: 1012312013
DETACH HERE
REFUND $395.10 KEY BENEFIT REPROCESSED CLAIM.
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCEJ- $0.00
Pay online at www.govpaynet.com with PLC#7487 Run Number 20134754:1
Online Payment will charge a service fee.
Date.of Service-!" Des.criptiod.:=:._ `Patient,Name, Charge(s). . .Date Payment(s).
Charges
10/23/2013 'ADVANCED LIFE MIHAL, CATHERINE J $475.00
10/23/2013 *MILEAGE MIHAL, CATHERINE J $18.88
---------------------------------
Charge Total: $493.88
Payments
Paid By: Invoice 10/23/13 $493.88
Paid By: MIHAL, CATHERINE J Payment 11/14/13 ($493.88)
Paid By: KEY BENEFIT COMMERCIAL INSURANCE 02/27/14 ($395.10)
Paid By: MIHAL, CATHERINE J REFUND 06/16/14 $395.10
BALANCE $0.00
113 197191S0191
KEY BENEFIT ADMINISTRATORS Explanation of Benefits
PO Box 55210 P
Indianapolis, IN 46205
Provider COPY
For Customer Service o•24-hour Medical
Forwarding Service Requested Eligibility VeriCcati on, please call w
2100-331-4757 or online at: v ww.kbasolution.com o
�I
3-DIGIT 460 Employee's: View your C1 iims/EOBs online at
9737 0.94314 AT 0-403 www.l:basoltif ion.com
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Employee: CATHERINE.[ MIIIAL.
CARMEL FIRE DEPT 50
2 CIVIC SQ Patient: CATHERINE.I Ml IAL
CARMEL, IN 46032-2584 Patient#: 201347541
Group#: 9009
Group: BAL STATE UNIVER>ITY
RECEIVED FEB 26 2014 Location: 3011
Claim#: 13088601-01
Date: 02/14/2014
Check#: 00432845
Send Hedical Clai ms Electronically
ebtillTyl ;`}=y, Niifl
t :i of yi Ymue lr 7P 'i'�i
Service Description/ Total Negotiated Code IneligibleCo-pay Deductible Covered Pay Co-Insurance. Amount
Incurred Date Charge Discount Charge % Payable
AMBULANCE 475.00 0.00 0.00 0.00 0.00 475.)0 80 95.00 380.00
10/23--10/23/2013
ANI1311LANCE 18.88 0.00 0.00 0.00 0.00 1818 80 3.78 15.10
10/23--10/23/2013
493.88 0.00 0.00 0.00 0.001 493. 1 98.781 395.10
Other(arrier Paymenl Amount: 0,00
Tot:I Plan Payment Amount: 395.10
rylessaLes _
Payrment based on Medicarc'aliproved amotmt .
*** ALWAYS USE PPO PARTICIPATING PROVIDERS TO RECEIVE THE HIGl-11"ST CLAIN4 REIMBURSEMENT ANC SAVINGS. PLEASE ,
REMEMBER TO FOLLOWTHE iNIAILING DIRECTIONS ON TLIE ID CARD TO ENSURE THE PROPER PPO PAR''ICIPATING PROVIDER OR
NON-PARTICIPATINCr PROVIDER BENEFIT HAS BEEN PAID.
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Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Farm 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 I have audited same in accordance
with IC 5-11-10-1.6.
20
Clerk-Treasurer
I
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
�o-
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund