HomeMy WebLinkAbout246229 06/17/15 CITY OF CARMEL, INDIANA VENDOR: 369482
® ONE CIVIC SQUARE CAINE&WEINER CHECK AMOUNT: $*******1 1 1.58*
CARMEL, INDIANA 46032 PO BOX 5010 CHECK NUMBER: 246229
WOODLAND HILLS CA 91365 CHECK DATE: 06/17/15
ON
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 REIMB 111.58 PODOLYAN
t
1 F
Y � R
C� 3� EL
JAMES BRAINARD, MAYOR
June 15, 2015
Caine & Weiner
P.O. Box 5010
Woodland Hills, CA 91365-5010
RE : C & W Account# 8911048
Dear Carmen Ruell:
We have received your letter for Svitlana P6dolyan. Reason for overpayment:
Anthem Medicaid paid this claim in error. The patient's primary insurance is Anthem
Blue Cross & Blue Shield. The overpayment is$ 111.58 to be sent to Caine & Weiner
Recovery.
If you have any questions, please feel free to contact me at(3 17) 571-2604.
Sincerely,
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
CARMEL FIRE DEPARTMENT
2 CIVIC SQUARE
w CARMEL, IN 46032-2584
(317) 571 2604 Federal ID#356000972
Patient Name: PODOLYAN, SVITLANA
SVITLANA PODOLYAN CARMEL FIRE DEPARTMENT
1004 TIMBER CREEK DR APT 2 2 CIVIC SQUARE
CARMEL , IN 46032 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 06/15/15 990105157
Ticket# : 20134770:1
Date of Service: 10/24/2013
DETACH HERE
REFUND ANTHEM MEDICAID $ 111.58
CLAIM PAID IN ERROR. PRIMARY IS ANTHEM COMMERICIAL. PATIENT WAS PAID BY ANTHEM
I AND NEVER PAID OUR BILL SENT TO COLLECTIONS.
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE $0.00.`
Pay online at www.govpaynet.com with PLC#7487 Run Number 20134770:1
Online Payment will charge a service fee.
Date of Serviced Description Patient Name Charges) Date` Payments)
Charges
10/24/2013 'BASIC LIFE SUP PODOLYAN, SVITLANA $375.00
10/24/2013 *MILEAGE PODOLYAN, SVITLANA $11.33
---------------------------------
Charge Total: $386.33
Payments
Paid By: Invoice 10/24/13 $386.33
Paid By: ANTHEM BLUE ASSIGNMENT MEDICAID 11/20/13 $274.75
Paid By: ANTHEM BLUE ASSIGNMENT MEDICAID 11/20/13 ($274.75)
Paid By: ANTHEM BLUE MEDICAID PAYMENT 11/20/13 ($111.58)
Paid By: ANTHEM BLUE CORRECTION 07/16/14 $111.58
Paid By. PODOLYAN, SVITLANA Bad Debt 08/25/14 ($386.33)
BALANCE $0.00
Prescribed by State Board of Accounts 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
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.
ALLOWED 20
C® Q- ��Q�� 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
JUN 15 2015
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund