247516 07/15/15 r Cqq-
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® '1 ONE CIVIC SQUARE TRICARE REFUNDS CHECK AMOUNT: $" .....333.23"
CARMEL, INDIANA 46032 ATTN:TRICARE NORTH REGION CHECK NUMBER: 247516
+Mrro„ PO BOX 870153 CHECK DATE: 07/15/15
SURFSIDE SC 29587-9753
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 333.23 OTHER EXPENSES
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JA.NrES BRmNARD, NkYOR
July 2, 2015
TRICARE REFUNDS
ATTN: TRICARE NORTH REGION
" P.O. Box 870153
SURFSIDE, SC 29587-9753
RE : TRICARE CONTROL# 5151750061 Account 420151486 :1
Dear TRICARE REFUND DEPARTMENT:
We have received your letter for DEWAYNE HOMAN. Reason for overpayment:
TRICARE first paid this claim in error as a secondary payer on April 30, 2015.
The patient's primary insurance is TRICARE from his wife's health insurance policy also
paid in full on $444.30 on June 23, 2015.
The overpayment is $ 333.23 to be sent to Tricare.
If you have any questions, please feel free to contact me at (3)17) 571-2604.
Sincerely,
/"j .
Michelle T. Harrington
EMS Billing Administrator
CAR\IEL FIRE DEPARTMENT
STEVTEN A. Cours HEADQUARTERS
Two CIVIC SOUARE. CARMEL. IN 46032 OFFICE �1 7.571.2600. FA-x 317.771.2615
0000894
TRICARE PO BOX 870153 CE NORTH REGION Health Net°
SURFSIDE BEACH, SC 29587-9753 FEDERAL SERVICES i R I C A R E'
JUNE 25, 2015
CARMEL FIRE DEPT AMBULANC
2 CIVIC SQUARE
CARMEL IN 46032
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Re: RCN: 51517500061
DEBTOR ID: 356000972
TOTAL DUE: $333.23
Dear Provider:
The purpose of this letter is to inform you we have improperly paid a claim(s).
The law requires we provide you with the following information:
Beginning April 22, 2015, we sent you payment(s) for medical services rendered to the patient(s) on the
attached report; however, we overpaid you in the amount of$333.23. Please reference the attached
report for detailed claim information including the reason for overpayment.
Payment in Full
To fully satisfy your debt within 30 days from the date of this letter, send a check or money
order for the total amount, made payable to TRICARE, to PGBA, LLC in the enclosed
self-addressed envelope. Please include the refund control number(RCN) on your check or
money order and the enclosed payment stub with your remittance to ensure proper credit to your
account.
- - - Partial or Delipiquent paymentsIf full payment is not received within 30 days from the date of this letter, your debt-will-be`
considered delinquent. Government agencies are required to collect interest on all delinquent
debts at the rate of 1.00 percent per year(this interest will accrue from the date of this letter).
If payment is not received within 60 days from the date of this letter, we are required to collect
payment by offsetting against future TRICARE claims submitted by you and/or any other provider
who shares your Federal Corporate Tax Identification Number(TIN) 356000972.
If payment is not received within 90 days from the date of this letter, federal agencies are
required to assess a penalty charge, not to exceed 6.00 percent per year, upon any portion of the
amount you owe and administrative costs. Administrative costs are based upon costs incurred in
processing and handling the case because it became delinquent.
TRICARE -North Region PGBA, LLC e Fax: 1-888-432-7077 • PO Box 870140 • Surfside Beach, SC 29587-9746
Customer Service: 1-877-TRICARE a www.myTRICARE.com by PGBA
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.
RMMS2NE/N1RQ/08K ckey:51517500061
Page 1 of 4
Health Net® ,E
FEDERAL SERVICES T R I C A R E®
Inspection and Review
You have the right to inspect all records pertaining to this debt.
If you believe this recoupment is incorrect, you have a right to request an administrative review of
indebtedness. Your request must:
1. be in writing;
2. be received by this office within 90 days from the date of this letter;
3. state specific reasons why you believe you are not indebted for the amount listed herein;
4. be accompanied by supporting documentation, such as bookkeeping and medical records,
and;
5. include a copy of this letter.
Send this request to:
TRICARE - North Region
PO Box 870140
Surfside Beach, SC 29587-9745
Financial Hardship
If you wish to request a compromise or installment plan based upon an inability to pay, you will be
required to complete a financial affidavit. If it then appears you are financially unable to make a
full refund at this time, you may be eligible for a payment plan to repay the debt. Please note that
any payment plan will include an interest charge at the rate specified above.
Your cooperation and prompt attention to this matter are appreciated.
For additional assistance, please contact customer service toll-free at 1-877-TRICARE (1-877-874-2273)
or send a confidential, secure e-mail through AskUs at www.myTRICARE.com.
Sincerely,
TRICARE - North Region
Refund Department
TRICARE-North Region PGBA, LLC . Fax: 1-888-432-7077 • PO Box 870140 • Surfside Beach, SC 29587-9746
Customer Service: 1-877-TRICARE • www.myTRICARE.com by PGBA
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.
RMMS2NE/N1RQl08K ckey:51517500061
Page 2 of 4
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PGBA, LLC. REPORT RMMSB740-01 PAGE 1
COLUMBIA SC 29219 ! CYCLE DAILY
R144SR740 5 810 NR NRI CLAIM DETAIL
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RCN: 51517500061
PROVIDER NUMBER: 1154325579 I
PROVIDER NAME: CARMEL FIRE DEPT AMBULANC
STREET ADDRESS: 2 CIVIC SQUARE
CITY, ST, ZIP: CARMEL IN 46032
CHECK CHECK BILLED PAID CORRECT REFUND RFND
PATIENT ACCT # PATIENT NAME SSN CLAIM NUMBER DATE AMOUNT DATE(S) OF SERVICE CHARGES AMOUNT AMOUNT AMOUNT RSN
20151486;1 Dewayne Holman *****6208 B105E02430001 04/22/15 $ 333.23 03/27/15 03/27/15 $ 515.02 `4 333.23 $ 0.00 $ 333.23 E05
Claims = 1 TOTALS i$ 333.23 $ 0.00 $ 333.23
Untimely kInterest = 0 TOTALS $ 0.00 $ 0.00 $ 0.00
REFUND TOTALS !$ 333.23 $ 0.00 $ 333.23
REASON FOR OVERPAYMENT:
E05 THE CLAIM PROCESSED AS TRICARE STANDARD; HOWEVER, THE PATIENT WAS ENROLLED IN TRICARE PRIME. THIS PROCESSING ERROR CREATED AN OVERPAYMENT.
To access detailed recoupment information, please sagn in to myTRICARE Secure at www.myTRICARE.com.
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Page 4 of 4
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CARMEL FIRE DEPARTMENT
Y... D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
r (317) 571 2604 Federal ID#356000972
Patient Name: HOLMAN, DEWAYNE
DEWAYNE HOLMAN CARMEL FIRE DEPARTMENT
5620 KENYON TRAIL 2 CIVIC SQUARE
NOBLESVILLE, IN 46062 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date I Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/02/15 990109954
Ticket# : 20151486:1
Date of Service: 3/27/2015
DETACH HERE
REFUND TRICARE $ 333.23
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE $0.00.
Pay online at www.govpaynet.com with PLC#7487 Run Number 20151486:1
Online Payment will charge a service fee.
Date°of;Service.: " `D'escription ` ' Patient Name:.V'`; ;�' Char e s Date`. Payment(sj:-=ti5
_ 9O'-
Charges
3/27/2015 "ADVANCED LIFE HOLMAN, DEWAYNE $475.00
3/27/2015 "MILEAGE HOLMAN, DEWAYNE $40.02
---------------------------------
Charge Total: $515.02
Payments
Paid By: Invoice 03/27/15 $515.02
Paid By: TRICARE FOR LIFE/7890 WRITE OFF-INSURANCE 04/30/15 ($70.72)
Paid By: TRICARE FOR LIFE/7890 COMMERCIAL INSURANCE 04/30/15 ($333.23)
Paid By: HOLMAN, DEWAYNE COMMERCIAL INSURANCE 06/23/15 ($444.30)
Paid By: TRICARE FOR LIFE/7890 REFUND 07/02/15 $333.23
BALANCE $0.00
Prescribed by Stale 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
20Clerk-Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF $
-ter
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
JUL 9 3 209
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20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund