HomeMy WebLinkAbout255839 03/01/16 J! CITY OF CARMEL, INDIANA VENDOR: 367078
f 31 ONE CIVIC SQUARE I U HEALTH PHYSICIANS CHECK AMOUNT: $*******378.57*
x =�; CARMEL, INDIANA 46032 PO BOX 627 CHECK NUMBER: 255839
COLUMBUS IN 47202 CHECK DATE: 03/01/16
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DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 022516 378.57 OTHER EXPENSES
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JAMES BRAL TARD, MAYOR
February 8, 2016
IU HEALTH PLANS
P.O. BOX 627
COLUMBUS, IN 47202-0627
ATTN: FINANCE DEPARTMENT
RE : IU HEALTH PLAN Account#20153998 :1 JOY GRAVES-RUST
Dear FINANCE DEPARTMENT:
We have received your payment for claim 0001780497 for$378.27 on 01/05/2016.
Allstate Insurance is primary and paid the claim in full $420.30 auto accident.
Refund$378.57 to be issued to IU Health Plans.
If you have any questions,please feel free to contact me at (317) 571-2604.
Sincerely,
AJ14,
Michelle T. Harrington
EMS Billing Administrator
CARMEL FIRE DEPARTMENT
STEVEN A. COUTS HEADQUARTERS
TWO CMC SOUARF.. CARMEL. TN 46032 OFFIC:F ',17.571.26nn. FAX x,17.571.2615
Health Plans t_r.r 1,I i of 1
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ATTENTION:PROVIDER SERVICES
IU Health Pians
PO BOX 627 Explanation of Payment lac)
COLUMBUS IN 47202.0627
Forwarding Service Requested RETAIN FOR TAX"PURPOSES
THIS IS NOT A BILL
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xY xx:flz s*s k xxx t *ALL FOR AADC 460 This is a summary ofa claim(s)recently processed.For
27717 1 AB 0.416 110tlues[iona mgar, Calmspieasavistivrrw.iuroalUlplans.org.
3elebt"(ravider to to check eligibility;benefits,claim status,
CARMEL RR£Dl, ARTIWINT submit and Verify authorizattans,obtain important forms and
2 CIVICSQUARr more.
CARWL IN 4032-7543
To reach IV Health Plans by phone:317-811 170
Group NPI No.:1154125570
Run Cal 12/2312015
Check#: 401026478
Check Amount:3370.27
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NEW
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rn;.e procedure Ory BiAad AdjustedExp Alloinsurance Co•pay Oeduoti a of ,4.Y t 1 Net Not
Dates Crile Amount Amount Code Arnount Amount Amount Amount Covered Paid Wr,46
;d
1 W9 1 .,373.00 '2,4,1 $375,00 $37.50 $0.00 $U.00 so'co 14.6 S0. 5$ 3.5 3 7.'
03'3);-:.OiU7120i5 .00425 0- 305.34 SO.UO ,d.f 545.90- 94.53 $0.00 SUM $0.00 $0,00 50.00 540.7: .7
Claims Sub•Tota. $420.30 50.00 $420.30 $42,03 $0.00 $0.00 $0.00 330.00 $0;00 $378,27 5378,27
Provider.,"
CARPlL_FIRE.6 'ARThRENT ...;:.;' r- 4; •.. t, {,
8illod Alloyed Coinsurance Co pay Deductible Not WIM f OIC Net Net+ Check
Amount Amount Amount Amount Amount Covered Paid WIFIS Total
5420.30 $420,30 $42:03 $0,00 $0.00 $0.00 $0,00 $0.00 $378.27 $378,27 $378.27
'1 Member is at or over the Maximum Limit for AGG Ind r Pam Calendar 0eductiole-By Mbr Tiers.
2 537.50 was applied for liability 53750 Ind 157500 tam AGG Cal OOP Tier f-Mbr Tiers
3 $4.53 was applied for liabi;iry S3750 Ind!57500 fam AGG Cal OOP Tier 1-III Tate.
Contract overedo was set to CON 80,
PNC BANK 401 028475
I 201 East FtRh 5troet
1 r Clncluma fi 43202
Alth,Plans seaae Check Date 12/2412015
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"PAY *"#Three.Hundred Seventy Eight Doliars acid Twenty Seveirtents
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' VOIDAFTER190-DAYS
TO THE CARMEL FIRE DEPARTMENT
ORDER OF 2:CIVIC SQUARE
CARMEL IN: 6032
Authorize B, i
it i0 26 t.?811:01. 120 389 51:4 260 59 70.6av
' ALLSTATEPROPERTYAND CASUALTYINSUR.4NCE COMPANY
PO BOX 2874 (WAI'smte'
CLINTONIA 52733-2874 You're in good r+e�a
• • • I Wig LYA
Date: 01/20/2016
Bill Received Date: 01/08/2016
Service Provided For: Claim#: 0382565703-01
JOY RUST File Handler: 2M2
552 STAFFORD DR Invoice#: 201539981
WESTFIELD IN 46074-5809
Injured Person: JOY RUST
Treatment Rendered By: CARMEL FIRE DEPARTMENT
Provider Specialty:
TIN: 35-6000972
NPI:
CMS ID:
Diagnosis Codes/Present on Admission Indicator
V99.XXXA Diagnosis code not found in ICD-9 co
Date of Service(s) Procedure/Revenue/NDC Billed Covered Reason
Prom Thru Code/Modifier Description Units Amount Amount Code(s)
08/07/15 08/07/15 M9999 Miscellaneous (The Proce 1.00 $ 375.00 $ 375.00
08/07/15 08/07/15 M9999 Miscellaneous (The Proce 1.00 $ 45.30 $ 45.30
Total: $ 420.30 $ 420.30
Eligible Amount Based on 100% of Covered Amount $ 420.30
If you have any questions about this claim, please contact your file handler,
KELLY RANKIN at (866) 575-4363 ext 9817565
Payment for $ 420.30 was made on 01/20/2016 to:
CARMEL FIRE DEPARTMENT
Copy(s) of this Explanation of Benefits has been sent to:
LEE CHRISTIE, 951 N DELAWARE ST INDIANAPOLIS, IN, 46202-3377
CARMEL FIRE DEPARTMENT, 2 CIVIC SQ CARMEL, IN, 46032-2584
160120001341RO217 0002690
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