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HomeMy WebLinkAbout304234 10/19/16 y u�..5dg� ay CITY OF CARMEL, INDIANA VENDOR: 371249 ® l ONE CIVIC SQUARE INDIANA UNIVERSITY HEALTH CHECK AMOUNT: $*******665.54* ;9 ,?� CARMEL, INDIANA 46032 2046 RELIABLE PKWY CHECK NUMBER: 304234 .y�«oN c� CHICAGO IL 60686-0020 CHECK DATE: 10/19/16 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 301 5023990 082416 665.54 OTHER EXPENSES 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 INDIANA UNIVERSITY HEALTH Purchase Order No. 2046 Reliable Pkwy Terms Chicago, IL 60686-0020 Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 08.24.16 6.24.i6 Te eeffeet healthGaFe overGharge to employee $665 54 666.6 Total hereby certify that the attached invoice(s), or bill(s), is (are)true and correct and I have audited same in accor- dance with IC 5-11-10-1.6. 20 Clerk-Treasurer September 14,2016 cattutty -nmetrteln fur; Indiana University Health PATIENT: - �-__ ACCT#;9356734 . 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N.`t�'c:x;�•�K:-x$>}t 455250597•08/09!16 lU Health North Medical Center 1,590.00 0.00 2,255.54 Outpatient-CAT Scan NEw 08124/2016 Insurance Contractual Adjustment(Anthem Blue Ar, $1,650.00 NEW 08/24/2016 Insurance Payment(Anthem Blue Access PPO) -$984.46 40019104-08109116 IU Health Physicians 223,00 I 0.00 0.00 Group No:22-Provider.LISA YOUNGBLOOD MD NEw 08/2412016 ANTHEM/BOBS PAYMENT $108.60 NEw 08/24/2016 Insurance Contractual Adjustment(ANTHEM/BCBS PA -$114.40 I 40062403-08109116 lU Radiology Associates 251.00 0,00 0.00 Group Na:20-Provider:KEVIN SMITH MD NEty 08/31/2016 ANTHEM/BCBS PAYMENT 5101.89 N£w 08/3112016 Insurance Contractual Adjustment(ANTHEMIBCBS PA x149.1 i I 38845286.05125116 IU Health Physicians 156.00 0.00 0.00 Group No.26-Provider:CARY N MARIASH MD ; 06!0812016 Adjustment(ANTHEM/BCBS PAYMENT) -495.00 I New 08/11/2016 BNK CHECK -$61.00 TOTAL $2,220.00 $0.00 $2,255.54 © - ee• . 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Group Health Plan Claims Detail Page �D•D ,^om 11011r,11 Z F,111s Q HELP qLUGUFF BlueCato�s�sBu (0Ma iD�p Health � lY - Services You are here: GHP Home > Claim Search>Claim Search Summary>Claim Detail Subscriber Name: Group Name: City of Carmel Subscriber ID Number: Group Number: 004007834 Maim Summary Member Name' Claim Number: 20162300114000 Member Relation: Adjudicated Date: 08/19/2016 Member Gender: dNW Type: MemberBirthday: �p Facility Payee: Provider Provider Name: INDIANA UNIVERSITY HEALTH NORT -narge 'DsduCtibls? 'Ginatlrance Co- Subscriber A,i?proxreo vitttLl r 7� 001.0 08109/2016- Outpatient LiabffllV to Pay 08/09/2016 Facility $1,590.00 $2,255.54 $0.00 $0.00 $2,255.54 $984.46 Approved Totals $1,590.00 $2,255.54 $0.00 $0.00 $2,255.54 $984.46 1 A`• D '-)Registered marks Blue Cross and Blue Shield Association.©2016 copyright of Anthem Insurance Companies, Inc. Anthem Blue Cross and Blue Shield is the trade name for the following: In Connecticut:Anthem Health Plans,Inc. In Colorado: Rocky Mountain Hospital and Medical Service, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky:Anthem Health Plans of Kentucky,Inc, in Maine:Anthem Health Plans of Maine, Inc. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. In New Hampshire:Anthem Health Plans of New Han Company. In Virginia: Anthem Health Plans of Virginia, Inc. Independent licensees of the Blue Cross and Blue ShieldAssociat on,shire, Inc. ISerry ng community sidentst ainsurance nd businesses in Indiana, Kentucky, Ohio, Colorado, Nevada, Connecticut, Maine, New Hampshire and Virginia(excluding the city of Fairfax, the town of Vienna and the area east of State Route 123). Use of the Anthem Web Sites constitutes your agreement with our Terms of Use https://pd2.s ecure.ant hem.com/nep/C C Servl et **INVOICE TO CITY OF CARMEL HEALTH FUND** (To correct healthcare services overcharge to employee as a result of inordinate contractual obligation between healthcare facility and Anthem.) Amount ..........................................................................................$ 665.54 Payable to INDIANA UNIVERSITY HEALTH Please deliver check to Sue Wolfgang in Human Resources Submitted To OC 2016 Ci8 k 3 'S- u re P r "INVOICE TO CITY OF CARMEL HEALTH FUN®** (To correct healthcare services overcharge to employee as a result of inordinate contractual obligation between healthcare facility and Anthem.) Amount ..........................................................................................$ 665.54 Payable to INDIANA UNIVERSITY HEALTH Please deliver check to Sue Wolfgang in Human Resources �0