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HomeMy WebLinkAbout233811 06/18/14 (9, CITY OF CARMEL, INDIANA VENDOR: 368324 ONE CIVIC SQUARE CATHERINE MIHAL CHECK AMOUNT: $*******395.10*CARMEL, INDIANA 46032 1259 BENTLEY WAY CHECK NUMBER: 233811 CARMEL IN 46032 CHECK DATE: 06118114 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 395.10 OTHER EXPENSES u CITY ' �F X. JANIEs BRAIv_ARD, MAYOR June 16, 2014 Catherine Mihal 1259 Bentley Way Carmel, IN 46032 RE: Ticket# 20134754:1 D.O.S. 10/23/2013 Dear Catherine Mihal: Enclosed you will find a reimbursement check in the amount of$ 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 Il'I'!'11111Llllil1111111'lllllllllltllllttlllllttlllllee�llltl� 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. FOR,-SECURITYPURP.OSES;-_THE'FACEI-OF,THISjDO'CUMENT";CONTAINS ®""=sA'.BLUE BACKGR0UND-AND;MIC1IOPRINTINGiiIN;THE]BORDER:;':':"%.;;:;,`:"- V SG ISJ ?13At.L- \'C'. It I�'F 41 ,Y S Ti C l ,R f H.�CiK; 1U: 0'43 0 2$45. 000 Oniversityk, nue4 i ' " 0Ofttc flie Conti'II ;e.i ` "CPalatiieNo. fO38'6(0134I 7541 , ,DTE 141 014 nt,l.1Vluncie;:IN 47306 . et.No.: _ .AMOUNT' .`PAY THREE HUNDRED NINETY-FIVE DOLLARS AND 10 CENTS' 10 TOTHE CARMEL FIRE DEPS' ORDER OF JP MORGAN CIIASE BANK N.A. y COLIIbinIIS OII � —!J 0 Void aflcr 90 days z Autl Drized S121,ature DO.NOT,CASH-IF.WATERMARKAS NOT:P.RESENT.ON THE REVERSE SIDE'-OF:TF IS,' CiAN:'ANGLEfTOIEW u°0043284 Su' 1:00, 11S4431: 817729304ne 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