HomeMy WebLinkAbout235323 7 /30/2014 �u!.4'!P,y
CITY OF CARMEL, INDIANA VENDOR: 366535
I ® ONE CIVIC SQUARE ACCENT CHECK AMOUNT: $*******550.50*
�_�; CARMEL, INDIANA 46032 PO BOX 952366 CHECK NUMBER: 235323
y�TON�, ST LOUIS MO 63195-2366 CHECK DATE: 07/30/14
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 REFUND 550.50 13-0758-9083360
I
CITY OF MR- MEL
JANWS BRAINARD, MAYOR
July 28, 2014
Accent
PO Box 952366:
St. Louis, MO 63195-2366
RE : Overpayment for Account#2013567:1 Whitney Robertson
Dear Laura Rossow:
Account## 13 0758 9083360 Request for refund is enclosed for$ 550.50.
This account Cigna paid in full by check#00340314933 on January 28,2014.
Now we have been told this claim was processed in error by Cigna and we have to
return payment. The date of service was 12/19/2013 and her insurance terminated
on 08/31/2013.
If you have any questions, please feel free to contact me at (317) 571-2604.
Sincerely,
Michelle T. Harrington
Billing Administrator
CARMEL FIRE DEIARTMrNT
STEVEN A. CCWTS HFALIQUARTERS
T%o CIVIC SQUARF, CARMEL, IN 46032 OFFicF. 317.571.2600, FAx 317.571.2615
Dept 19425
PO Box 1259
Oaks, PA 19456
PLEASE DO NOT MAIL PAYMENTS TO IIIIIIIIIIIIIIIIIVIIIVIIII IIIIIIIIVIIIVIIIIIIIIVIIIVIIIIIIIIIIIIIIIIIIIIIIIII THIS ADDRESS . / (MA
(or
Correspondence Address:
March 29, 2014 7171 Mercy Road
PO BOX 69004
Omaha, NE 68106-5004
IIIIIII'I�I�'IIT��I�III��I'II� ��I�I'�II�III"'�'�II"'��I'I�I 88586-365 Phone: 888-633-5516
CARMEL FIRE DEPT Nebraska: 402-384-5100
2 CARMEL CIVIC SQ TTY Phone: 800-833=7352
CARMEL, IN 46032-2584
ACCOUNT NUMBER: 13 0758 9083360
Re: Request for refund of overpayment. (Tin#: 356000972)
Accent Cost Containment Solutions ("Accent") has been enlisted by CIGNA,HEALTHCARE PROCLAIM to recover the amount
indicated below.
We respectfully request your remittance in full, payable to either Accent or to the above mentioned client. Please send the
refund or contact our office within 30 days of the date of this letter.
For questions about this request, contact our office directly or submit your inquiry in writing to the correspondence address
indicated above. .
Respectfully,
d�Ce:Gllll
LAURA ROSSOW
Recovery Specialist
Accent
1-888-633-5516 ext. 56396
Business Hours- CST:
Monday-Thursday 7:00 a.m. to 5:00 p.m.
Friday 7:00 a.m. to 3:45 p.m.
The overpayment identified is for the below customer and correlates to the following claim(s):
Amount Due: $550.50
Reason: termination of benefits
Customer Name: WHITNEY A ROBERTSON
Dates) of Service: 12/19/2013 .
Total Charges: $550.50
Total Paid:. $550.50
Plan Participant: WHITNEY A ROBERTSON
Patient Number: 201356711
Payee Name: CARMEL FIRE DEPT
Term Date: 08/31/2013
Reason for Termination: INDIVIDUAL TERM
See Reverse for Calculations
365-88586-DOCOPI TEAR ALONG LINE AND RETURN LOWER PORTION WITH PAYMENT
Account Number: 13 0758 9083360
Account Number: 13 0758 9083360
Actual:
Claim Account Date of Procedure Charge Allowed Customer Benefit Check Check
Number Number Service Code Liability Number Issue
Date
96514004- 201356711 12-19-2013 A0427 $550.50 $550.50 $0.00 $550.50 340314933 01-21-2014
016830001 to 12-19-2013
Total $550.50 $550.0 $0.00 $530.50
Recalculated:
Claim Account Date of Procedure Charge Allowed Customer Benefit Check Check
Number Number Service Code Liability Number Issue
Date
96514004- 201356711 12-19-2013 A0427 $550.50 $0.00 $0.00 $0.00 340314933 01-21-2014
016830001 to 12-19-2013
Total $550.50 $0.00 $0.00 $0.00
Prescribed by State Board of Accounts City Form No.201(Rev.1995)
ACCOUNTS PAYABLE VOUCHER
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))
If --_
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
20Clerk-Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF $
ON ACCOUNT OF APPROPRIATION FOR
j 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
28 2n16 20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund