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Home My WebLink About255880 03/01/16 - VOID J`%�"p''� CITY OF CARMEL, INDIANA VENDOR: 358211 ONE CIVIC SQUARE L C P TRANSPORTATION CHECK AMOUNT: $*******169.66* s9 i+° CARMEL, INDIANA 46032 PO BOX 531097 CHECK NUMBER: 255880 M,�ioN��. INDIANAPOLIS IN 46253 CHECK DATE: 03/01/16 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 022516 169.66 OTHER EXPENSES VOUCHER NO. WARRANT NO. ALLOWED 20 IN SUM OF $ ON ACCOUNT OF APPROPRIATION FOR Board Members PO#DEPT. # DEPT. INVOICE NO. ACCT#/TITLE AMOUNT 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 FEB 1 7 2916 f Al 20 Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund f `� rF I'I'I O1FAl�1VIEL JAMS BRmNARD, MAYOR February 8, 2016 LCP TRANSPORTATION LLC P.O. BOX 531097 INDIANAPOLIS, IN 46253-1097 ATTN: ADJUSTMENT DEPARTMENT RE : LCP TRANSPORTATION Account#20153462 :1 ArA4 A l le—n Dear ADJUSTMENT DEPARTMENT: We have received your payment for claim LA1015201031 for$169.66 claim processed and paid at Medicaid rate on 09/1/2015. The claim was reprocessed and paid$417.10 Claim Correction LA4015236080 for HIP plan. Duplicate payment received 10/01/2015 Refund$169.66 to be issued to LCP Transportation LLC. If you have any questions, please feel free to contact me at(3 17) 571-2604. Sincerely, ov"llao-1-Z Michelle T. Harrington EMS Billing Administrator CARD'IEL FIRE DEPARTMENT STEVEN A. COUTS HEADQUARTERS Two Civic SQUARE, CARMEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615 LAIgibtltty Inquiry Page 1. of 2 Eligibility Inquiry interChange Home Query Information Indiana Medicaid NPI1164325579 TaxonomyCodei - --�—� Postai code��}E j Administration Menu Cheek/RA Inquiry Search CriteriaBy Member Ip _ Claim Inquiry Member ID 103695"006699 Claim Submission From Date 07/1 112 01 5 ...w To pate 10711y2o15 ° j Eligibility Inquiry Search Resat PA Inquiry PA Submission Eligibility information Provider Profile Member is Eligible from 07111!2015 to 07/1112015 for HIP State Plan BASIC User Lists Inquiry completed at 2:55:33 PM on 7/1512015 User Profile Member Name AMY ALLEN Member ID 103695606699 Address 3016 N 150 W Help LEBANON,IN 46052.0000 FAQ Date of Birth 10/2611976 Spendda vnlHCBS Waiver Liability No How to Obtain an ID Medicare No Medicare Number Contact US Nursing Horne Resident No Patient Liability $0.00 Restricted Yes Copay Yes Logon OMB No Logoff Other Private Insurance No Low Income Yes Change Password r-SpenddowntHCBS Waiver Liability None Managed Care Information -- Managed Care Healthy Indiana Plan from 0 711 112 01 5 to 07/11/2015 Primary Provider ERB.JILLIAN K. Phone 317.756-4477 Managed Care Entity Name MANAGED HEALTH SERVICES-HIP Phone 877.647-9846 Member is restricted to Show More Provider Name Provider Type RIVERVIEW HEALTH Hospital MICHAEL SERMERSHEIM Performing Provider KATHERINE KOBZA Performing Provider ERB,JILLIAN K. Performing Provider WAL-MART PHARMACY 910-1275 Pharmacy Third Party Carrier information Nene TPI..li'r;r'ate R,gy1,Ft t County Information Show County Info FBenefit Limits Reached For Inquiring Provider Type 1hips://interchange.indiatianiedicaid.com/Member/EligIngtiiryHIPAA.aspx?servLoc=&sak... 7/1512015 Provider Name:CITY OF CARMEL FIRE DEPARTMENT-AMB SER Provider Number:200124160 Provider Address:2 CIVIC SQ NPI: 1154325579 Provider Phone Number:3175712600 CARMEL IN 46032-2584 Adjusted Claims ICN Number:LA3015259006 Member Name:ALLEN,AMY Medicaid ID: 103695606699 RA Date:10/1/2015 Status:Paid Deny Reason:Member Ineligible. Date of Birth: 10/28/1978 Date of Service:7/11/2015 Billed Billed Billed Amt: TPL Amt: Total Billed: Prev Prev Prev Amt: Adj Adj Adj Amt: TPL Amt: Allwd Amt: LCP Notes: Diag Code: Unit: Code: Unit: Code: Unit: Code: A0425 2 $11.33 - $11.33 A0425-U1 2 $8.82 0 $0.00 - - 4275 A0427 1 $475.00 - $475.00 A0427 1 $160.84 0 $0.00 - - 4275 Totals: $486.33 $0.00 $486.33 $169.66 $0.00 $0.00 $0.00 Past Paid: $169.66: Net: ($169.66) Provider Summary For: CITY OF CARMEL FIRE DEPARTMENT-AMB SER New Claims:I Adjusted Claims:I Check Received with Adjustments: Total Billed:1 $0.001 $486.331 $0.00 Total Allowed: $0.00 ($169.66)1 $0.00 Gross Amount: ($169.66) Previous Balance: $0.00 Check(s)Received: $0.00 Net Due: $169.66 Page 21 of 64 Provider Name:CITY OF CARMEL FIRE DEPARTMENT-AMB SER Provider Number:200124160 Provider Address:2 CIVIC SQ NPI: 1154325579 Provider Phone Number:3175712600 CARMEL IN 46032-2584 New Claims ICN Number:LA4015222051 Member Name:WOODFORK,TASHIMEKA Medicaid ID: 101996140699 RA Date: 10/1/2015 Patient Acct#:201539081 Status:Paid Date of Birth:7/23/1974 Date of Service:8/3/2015 Billed Billed Billed Amt: TPL Amt: Bal Due: Allwd Allwd $/Unit: Allwd Amt: TPL Amt: Allwd Bal: LCP Notes: Diag Code: Unit: Code: Unit: Code: A0429 1 $375.00 - $375.00 A0429 1 $341.70 $341.70 - $341.70 Ambulance service,basic life support 723.1 (BLS) A0425 2 $12.84 - $12.84 A0425 2 $6.42 $12.84 - $12.84 ALS-Ground Mileage,per statue mile. 723.1 Totals: $387.84 $0.00 $387.841 1 $354.54 $0.00 $354.54 Net Due $354.54 L ICN Number:LA4015226054 Member Name:Wheaton,Dennis Medicaid ID: 106018496599 RA Date: 10/1/2015 Patient Acct#:201540041 Status:Paid Date of Birth:11/25/1955 Date of Service:8/7/2015 Billed Billed Billed Amt: TPL Amt: Bal Due: Allwd Allwd $/Unit: Allwd Amt: TPL Amt: Allwd Bal: LCP Notes: Diag Code: Unit: Code: Unit: Code: A0429 1 $375.00 - $375.00 A0429 1 $341.70 $341.70 - $341.70 Ambulance service,basic life support 5780 (BLS) A0425 2 $13.59 - $13.59 A0425 2 $6.80 $13.59 - $13.59 ALS-Ground Mileage,per statue mile. 5780 Totals: $388.59 $0.00 $388.59 $355.29 $0.00 $355.29 Net Due $355.29 to- ICN ICN Number:LA4015236080 Member Name:ALLEN,AMY Medicaid ID: 103695606699 RA Date:10/1/2015 Patient Acct#:201534621 Status:Paid Date of Birth: 10/28/1978 Date of Service:7/11/2015 Billed Billed Billed Amt: TPL Amt: Bal Due: Allwd Allwd $/Unit: Allwd Amt: TPL Amt: Allwd Bal: LCP Notes: Diag Code: Unit: Code: Unit: Code: A0427 1 $475.00 - $475.00 A0427 1 $405.77 $405.77 - $405.77 ALS 427.5 A0425 2 $11.33 - $11.33 A0425 2 $5.67 $11.33 - $11.33 ALS-Ground Mileage,per statue mile. 427.5 Totals: $486.33 $0.00 $486.33 - $417.10 $0.00 $417.10 Net Due $417.10 Provider Summa For: CITY OF CARMEL FIRE DEPARTMENT-AMB SER New Claims:I Adjusted Claims: Check Received with Adjustments: Total Billed: $1,262.761 $0.001 $0.00 Total Allowed: $1,126.931 $0.001 $0.00 Gross Amount: $1,126.93 Previous Balance: $0.00 Check(s)Received: $0.00 Net Due: $1,126.93 Page 2 of 19