HomeMy WebLinkAbout259375 06/10/16 i
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CITY OF CARMEL, INDIANA VENDOR: T0002820
jg ® 1 ONE CIVIC SQUARE CIGNA HEALTHCARE INC CHECK AMOUNT: $*******255.73*
_� CARMEL, INDIANA 46032 PO BOX 182223 CHECK NUMBER: 259375
''�ir'oei�°' CHATTANOOGA TN 37422 CHECK DATE: 06/10/16
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DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 201611343 1 255.73 OTHER EXPENSES
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VOUCHER NO. WARRANT NO.
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)
r--
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
In V� :9
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
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CITY OF! ARNIEL
Jr1tVIES BRAu,ARD, MAYOR
June 6, 2016
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CIGNA
P.O. BOX 182223
CHATTANOOGA, TN
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RE :OVERPAYMENT CIGNA Account#20161134:3 Shane Carney 03/02/2016
Dear Cigna:
Erie Insurance the primary insurance paid $500.00 and the balance due was $125.40.
Cigna secondary insurance paid$381.13. Overpaid amount$255.73.
Enclosed is a refund to Cigna for $255.73.
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If you have any questions, please feel free to contact me at (3 17) 571-2604.
Sincerely,
Michelle T. Harrington
EMS Billing Administrator
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CARMEL FIRE DEPARTMENT
STEVEN A. CouTS HEADQUARTERS
Two CIVT . SOTIARF CARmm. TN 460�;2 1 nFFTcF X17 571 ?(inn FAY x,17 171 2(,1 S
CNWZ1, CARMEL FIRE DEPARTMENT
f 2 CIVIC SQUARE j
CARMEL, IN 46032-2584
CLAX`�". (317) 571 2604 Federal ID#356000972
Patient Name: CARNEY, SHANE
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SHANE CARNEY CARMEL FIRE DEPARTMENT
1310 FAIRBANKS DR 2 CIVIC SQUARE
CARMEL, IN 46033 CARMEL, IN 46032-2584
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TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID AMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 06/06/16 200901533
Ticket# : 20161134:3
Date of Service: 3/2/2016
DETACH HERE
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ERIE INSURANCE PAID $500.00.AMOUNT DUE$125.40 FROM SECONDARY INSURANCE
CIGNA. CIGNA PAID $381.13. OVERPAYMENT DUE TO CIGNA $255.73.
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE
Pay online at www.govpaynet.com with PLC#7487 Run Number 20161134:3
Online Payment will charge a service fee.
Charge,(s) Date Payments)
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Date of ServiceDescnption'^ �PatientName t ' '
Charges
3/2/2016 *ADVANCED LIFE CARNEY, SHANE $575.00
3/2/2016 *MILEAGE CARNEY, SHANE $50.40
---------------------------------
Charge Total $625.40
Payments
Paid By: Invoice 03/02/16 $625.40
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Paid By: ERIE INSURANCE COMMERCIAL INSURANCE 04/12/16 ($500.00)
Paid By: CIGNA/ 182223 COMMERCIAL INSURANCE 05/20/16 ($381.13)
Gl<{ 00 313 7-,301
Paid By: CIGNA/ 182223 REFUND 06/06/16 $255.73
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BALANCE
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0.00
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Provider.Expianfatioar ofAledkxai Payment Report ,f-.Ggnl
,..... ............ . ........_..._ _......_ .._.............-...-.....................-'— ....----..._.... ._.............. ..........._ ....... _.. _
Pn)vulcr Numikr Prouder Name Date through which ciainli%,Lue procmed I IMS IS NOT A B111 1'0e
356D00972 0000 CARMEL FIRE DEPARTMENT 04/30/2016 1 Retain For Your Records I
-----^.. -- -— _...... ............_._ ...... _ .. _._ r ........._....._._...._ _._.
tt j AitlustLvl f_.._..:.,.._._,_ DN<, DRt,7
'• Ittx-eduto t Adjusted , Billed I, ! .Mowed'` '.ot Coi•ered/1>eductica 'Coinsurance + 'DRGIPec Dlcm{. .Per Dican i Ss
f:fn6 ! Procxtute Date.. '. - Proatiure ,1 ro<Ltiure CcwL� I Pay+ i(r Penn: Per p(tKn -DcncClt .Pian Rvoe.At
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code �� AlitouDt (mount "j Amount -Dls4'Ouut 1' Amount Amount AhC"type i 11(Wn ber+ Amamt tiol,
Reminder: A coverage determination, prior authorization, or certification that is made Prior to a service being performed Is not a promise to Pay for tGo —elce at any
particular rate or amount. The patlent's summary Plan doscription governs amount payable, as Avery claim submitted is subiect to all plan provisions, including, but not
limited to, eligibility requirements, exclusions, limitations, and applic hle state mandate:.
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PATIENT NAME: SHANE CARNEY PATIEN79: 2016/1343 OPERA4108 LOCATION/GP.OUP9 54416-9-3337655 RECEIVE DATE: 04118/20/6 PROCESS DATE: 04/30
HEER MARC: SHANE CARNEY SUBSCRIBERO: U51676656 REFB: 843161x196806 CIECKe: tl0393283014
MB
1 0$027.016 A0427 575.00 444.S5 110.45 88.91 0.00 0.00 355.64 AC
T+05022016 AD425 50.46 31.66 18.54, 6.31 0.00 0.00 25.49 AD
TOTAL 625.40 476.41 148.99 361.15
;THE$1,500 1N NETWORK DEWCTIBLE HAS eET1(SATISFIED FUR 2026
51,947.32 HAS BEEN APPLIED TOWARDS THE$5,000 IN NETWORK 'OUT-OF-POCKET LIMIT' FOR 2016
51,745.61 HAS BEEN APPLIED TOWARDS THE:2,500 OUT OF NETWORK DEDUCTIBLE FCR 2016
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$1,299.96 HAS BEEN APPLIED TOWARDS THE s15,000 OUT OF 4ETWD12K 'OUT-OF-POCKET LIMIT' FOR :016
BALANCE................... S244.Z7
VIEW ELIGIBILITY,BENEFITS, AND CLAIM DETAILS AND GET PRECERTIFICATION ANSWE
RS FAST AT TICE CIGNA FOR HEALTH CARE PROFESSIONALS WEBSITE (WWW.C1GNAFDRHCP.
COM)
1 PAYMENT OF 5381.15 TO CARMEL FIRE DEPARTMENT
-- - - - -- - - - - ------- ------ - -- SYS Mitt ---- - ----- --._---
1 AO)FOR OUT-Of-NETWORK SERVICES, CIGNA WILL REIMBURSE YOU
UP TO A SET MAXIMUM AMOUNT (KNOWN AS MAXIMUM
j REIMBURSABLE CHARGE IN YOUR PLAN BOOKLET). YOUR HEALTH
CAPE PROFESSIONAL MAY BILL YOU FOR ANYTHING ABOVE THIS
AMOUNT.
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G243SE D4-08-2015 Proclaim Provider EOP Summar
O a e e i l G A A 9 i
/III I/III 1111111111 All III 11111111