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Home My WebLink About242678 03/03/2015 Q CITY OF CARMEL, INDIANA VENDOR: T359686 ONE CIVIC SQUARE ANTHEM BLUE CROSS BLUE SHIELD CHECK AMOUNT: $.......400.02' CARMEL, INDIANA 46032 PO BOX 5281 CHECK NUMBER: 242678 CAROL STREAM IL 60197 CHECK DATE: 03/03/15 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 2/23/15 400.02 OTHER EXPENSES Anthem Blue Cross Blue Shield Page 1 of 2 PO Box 105557 ATLANTA,GA 30348-5557 . nffie - ire (9. B1ueCross B1ueShield IIS'Illill'�'I'n'oinl'Illl��llllll1100ollill'�il'�ililll'I��'r� 000003 1 SP 0.480 000074/001321/000147 001 02 AGSJ26 #W PT060LACRTCEN#1 012215 012315 CARMEL FIRE DEPT ® 2 CARMEL CIVIC SQ CARMEL, IN 46032 Dear valued customer, the enclosed letter provides detailed information on an overpayment that has occurred resulting in the requested refund amount of$400.02. Please detach the coupon below and -- include it-with-your check made payable to-Anthem'Illuu-Cra-s3-Biue Shield. -_ -- — _- 001321/147 AGSJ26(0)Si-ET-Mt-0002(74)1 PLEASE RETURN COUPON WITH YOUR PAYMENT - DO NOT STAPLE. Anthem a Page 2 of 2 BlueCross B1ueShield PO Box 105557 ATLANTA,GA 30348-5557 CARMEL FIRE DEPT Date: 01/22/2015 2 CARMEL CIVIC SQ Processing System: WG CARMEL, IN 46032 Provider ID: 1154325579 Letter ID: 4556877 Dear Provider, In review of our records,we have found that an overpayment exists. Our files indicate that a refund is due for the reason listed below. Medicare on this claim was either not applied or was applied incorrectly resulting in an overpayment. Member ID:XOT836951798 Patient: SHARLOTTE LLOYD Claim# Account# Service Date Amt.Paid Paid Date Check# Amt.Due. 2013224QA4913 201325151 06/14/2013 $480.29 08/28/2013 0308805909 $400.02 New Member Liability: $3.89 Total Refund Due: $400.02 The claims information listed above sets forth the reason for the overpayment recovery request. You may obtain more information about the decision by calling the phone number listed below. Refer to the provider manual or your provider contract for information regarding any appeal rights you have and how to appeal a decision. If we do not receive a written appeal from you within 30 days,we may recover the identified overpayment amount from you. Even after we recover the overpayment,you might have a longer period to appeal this decision as set forth in the provider manual or your provider contract. If you are a non-contracted provider and you disagree with this decision,please contact the number below for instructions on where to submit your written appeal. Please send the coupon,your check and a copy of this letter within 30 days of the letter date. Please use regular US MAIL when responding to this letter. UPS,Federal Express, and other Commercial Carriers do not deliver to Post Office Boxes. If we do not receive a response within 30 days,we will initiate the recoupment process and deduct the overpayment from future remittances. If you would like immediate recoupment of the entire amount from a future remittance(s), sign,date,and fax this letter to(317)287-8463. Your authorization for immediate recoupment of the entire amount will be processed upon our receipt. Name: Ae Title: Z Date: 2 /J__ You have the right to submit a complaint regarding the above decision. A letter setting out the complaint along with a copy of this letter should be sent to us within 30 days from the date of this notice to the address listed at the top of this letter. You will be notified of a decision as soon as the review of the complaint has been completed. 001321/148 AGSJ26(D)S1-ET-Mi-0002(74)1_ - - T Page 2 of 2 Provider is required to return, destroy or further protect the misrouted PHI received due to a recent incorrect payment of services. Misrouted PHI includes information about members that a Provider is not currently treating. You are required to immediately destroy any misrouted PHI or safeguard the PHI for as long as it is retained. In no event are you permitted to misuse or re-disclose misrouted PHI. If you engage in electronic transactions with us,please note that the overpayment identified in this notice has not yet been reflected in your electronic remittance advice. The correction will be reflected either after you return the overpayment, or in a remittance advice showing the electronic recoupment. Thank you for your attention to this matter. Toll Free: 8665940521 ext.: Letter ID 4556877 Anthem Blue Cross and Blue Shield is the trade name of:In Indiana:Anthem Insurance Companies,Inc.In Kentucky:Anthem Health Plans of Kentucky,Inc.In Missouri (excluding 30 counties in the Kansas City area):RightCHOICEO Managed Care,Inc.(RIT),Healthy Alliance®Life Insurance Company(HALIC),and HMO Missouri,Inc.RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri,Inc.RIT and certain affiliates only provide administrative services for self-fimded plans and do not underwrite benefits.In Ohio:Community Insurance Company.In Wisconsin:Blue Cross Blue Shield of Wisconsin (BCBSWi),which underwrites or administers the PPO and indemnity policies;Compcare Health Services Insurance Corporation(Compcare),Which underwrites or administers the HMO policies;and Compcare and BCBSWi collectively,which underwrite or administer the POS policies.Independent licensees of the Blue Cross and Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies,Inc.The Blue Cross and Blue Shield names and symbols are the registered marks ofthe Blue Cross and Blue Shield Association. 0013211148 AGSJ26(D)S1-ET-Mt-0002(74)1 CARMEL FIRE DEPARTMENT 2 CIVIC SQUARE CARMEL, IN 46032-2584 (317) 5712604 Federal ID#356000972 Patient Name: LLOYD, SHARLOTTE S SHARLOTTE LLOYD CARMEL FIRE DEPARTMENT 726 WILSON TERRACE CT 2 CIVIC SQUARE CARMEL, IN 46032 CARMEL, IN 46032-2584 TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID AMOUNT PAID THIS PORTION WITH YOUR PAYMENT 03/02/15 __-- -- --Ticket#-: ._2043251 990103801 8:1---- - 01 - Date of Service: 611412013 DETACH HERE MEDICARE IS PRIMARY AND ANTHEM IS SECONDARY. PAYMENT RECEIVED FROM ANTHEM PAYING THE CLAIM AS PRIMARY. OVERPAYMENT REFUNDING ANTHEM$400.02 MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE _ $0:00 Pay online at www.govpaynet.com with PLC#7487 Run Number 20132518:1 Online Payment will charge a service fee. e:�r':,^+� -+ F - err �. ,. -a•cr.,* ,.. .. Date.of Service Description ` Patient Name 'Charge(s) Date I Payment(s) : _ a �. _ Charges 6/14/2013 *ADVANCED LIFE LLOYD, SHARLOTTE S $475.00 6/14/2013 *MILEAGE LLOYD, SHARLOTTE S $5.29 --------------------------------- Charge Total: $480.29 Payments Paid By: Invoice 06/14/13 $480.29 Paid By: MEDICARE PART B ASSIGNMENT MEDICARE 07/11/13 ($85.36) Paid By. MEDICARE PART B MEDICARE PAYMENT 07/11/13 ($314.66) Paid By: ANTHEM BLUE CROSS & BLUE COMMERCIAL INSURANCE 09/10/13 ($480.29) Paid By. ANTHEM BLUE CROSS & BLUE REFUND 03/02/15 $400.02 BALANCE $0.00 ClS- OF A EL JAMES BRAINARD, MAYOR February 22,2015 ANTHEM BLUE CROSS BLUE SHIELD P.O. BOX 5281 , CAROL STREAM, IL 60197-5281 RE : Sharlotte Llyod DOS 06/14/2013 Dear Sir/Madam: Enclosed you will find a check in the amount of$ 400.02. This claim was paid by Medicare on 07/11/2013 and Anthem paid this claim as primary in error on 09/10/2013. Overpayment of$ 400.02 is due to Anthem Blue Cross Blue Shield. If you have any questions,please feel free to contact me at(317) 571-2604. Sincerely, Iva -- Michelle T. Harrington Billing Administrator CARMEL FIRE DEPARTMENT STEVEN A. CouTs HEADQuARTERs Two Civic SQUARE, CARMEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615 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)) 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 'I Clerk-Treasurer VOUCHER NO. WARRANT NO. r 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 20 OAR 12,915 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund