HomeMy WebLinkAbout239676 12/03/2014 CITY OF CARMEL, INDIANA VENDOR: T359686
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js ® ONE CIVIC SQUARE ANTHEM BLUE CROSS BLUE SHIELD CHECK AMOUNT: $'"""""'384.06*
CARMEL, INDIANA 46032 CENTRAL REGION-CCOA LOCKBOX CHECK NUMBER: 239676
PO BOX 73651 CHECK DATE: 12/03/14
CLEVELAND OH 44193-1177
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 384.06 OTHER EXPENSES
+ A
CITY O' CARIVIEI.
JAMES BRAINARD, MAYOR
November 14, 2014
_ Anthem Blue Cross Blue Shield
Central Region—CCOA Lockbox
PO Box 73651
Cleveland, OH 44193
RE : Claim# 14037YO67635BA#20140364 :1 Joseph Swiezy
Dear Michele Orange:
Anthem made an error and paid this claim in full $384.06 and the claim should have been
processed as a secondary payer not primary.
Enclosed is a refund $384.06 for this claim.
I have resent the claim to Medicare today and the claim will be resent to Anthem.
If you have any questions, please feel free to contact me at (317) 571-2604.
Sincerely,
J/ r4
��c� —
Michelle T. Harrington
EMS Billing Administrator
CARMEL FIRE DEPARTMENT
STEVEN A. CouTS HEADQUARTERS
Two CIVIC SQUARE, CARMEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615
x BlueCross.
BlueShield.
Federal Q9
Employee Pr ram.
Make Check payable and remit to Anthem
10/02/2014 Blue Cross Blue Shield(please include
enclosed letter and remittance.)
Joseph Swiezy
2345 W. 86Th Street
#220
Indianapolis,IN 462601905
Re: Patient Name:Joseph Swiezy
__ _.__... .__..._.._._ Iderififcation_Number_807723556 __.._._._....... ._...
Claim Number:14037YO67635BA
Date of Service: 1%16/2014
Provider of Service: CARMEL FIRE DEPT
Amount Paid: $384.06
Paid Date: 2/11/2014
Refund Amount Due: $384.06
Reason for Refund: Charges were billed in error
Dear Sir/Madam:
Our records indicate that Blue Cross Blue Shield Service Benefit Plan issued an incorrect payment for the claim,
reason and amount referenced above.Therefore,we are requesting a refund for this amount.
To ensure proper handHn , lease send our check or money order with a co of this letter in the enclosed self-
addressed l; P Y Y 1?Y
addressed envelope within 30 days.
Remit to: Anthem Blue Cross Blue Shield Disputes or Anthem Blue Cross Blue Shield
Central Region--CCOA Lockbox Inquiries: Federal Employee Program
PO Box 73651 - PO Box 105557
Cleveland, OH 44193 Atlanta,GA 30348-5557
If you have any questions,please call us toll free at 1-800-3382X520.
Sincerely,
Michele Orange
Recovery Specialist-IN
Prescribed by State Board of Accounts y 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
f
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
VOUCHER NO. WARRANT NO.
LOWED 20
IN SUM OF $
i
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
DEC - 9 201
I
/)JAO.
OIL),
AV
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund