HomeMy WebLinkAbout305936 12/12/16 CITY OF CARMEL, INDIANA VENDOR: T0002820 CHECK AMOUNT: S""""`""509.93`
ONE CIVIC SQUARE CIGNA
=Q CARMEL, INDIANA 46032 PO BOX 188012 CHECK NUMBER: 305936
�. CHATTANOOGA TN 37422 CHECK DATE: 12/12/16
y/iON
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 20164888 509.93 OTHER EXPENSES
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF $
ON ACCOUNT OF APPROPRIATION FOR
Board Members
Pon or INV NCE NO. ACCT#/TITLE
OIAMOUNT I hereby certify that the attached invoice(s), or
DEPT.#
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
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
CITY RMEL
J.1�IES BR�IINARD, NLkYOR
December 5, 2016
Cigna
P O Box 188012
Chattanooga, TN 37422
RE: Ticket#20164888:1 D.O.S. 08/30/2016 ICN 4651626501648 Shelly A. Ray
Dear Cigna Overpayment,
Enclosed you will find a refund check in the amount of$509.93.
We received your payment on October 04, 2016 for$509.93.
This is a worker's compensation claim that will be paid by Liberty Mutual.
Overpayment invoice—refund issued to Cigna for$509.93.
If you have any questions, please feel free to contact me at (317) 571-2604.
Sincerely,
Michelle T. Harrington
Billing Administrator
C_1R'lIEE Fiiu: DF11ARTMENT
SM EN A. COOTS HF DQI-ARTERS
Tvo CMC SQUARE, Gaiz�iF:E, IN 46032 Orr--io. 317571.2600, F.kl 317571.2615
DATE: 10/11/2016 835 Remittance Advice
CIGNA HEALTH AND LIFE INSURANCE COM CARMEL FIRE DEPARTMENT SUBMITTER #: 133052274 CHK/REF#: 160930090033927
P.O. BOX 182223 2 CIVIC SQ PROV/NPI #: 1154325579 DATE: 10/4/2016
CHATTANOOGA, TN 374227223 CARMEL, IN 460322584 TR SET: 000000001 AMT: 868.35
P.O. BOX 182223 2 CIVIC SQ PAYER ID:
- ---- -------
CHG CODE SERV DATE POS UNTS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC-AMT PROV PD
---------------------------------------------------------------------
------------------
NAME RAY, SHELLY A HIC U0710149201 ACNT 20164888-1 ICN 4651626501648
82143 1 A0427 SH 775.00 606.21 0.00 121.24 CO-45 168.79 484.97
82144 3 A0425 SH 31.20 31.20 0.00 6.24 0.00 24.96
PT RESPONSIBILITY 127.48 CLAIM TOTALS 806.20 637.41 0.00 127.48 168.79 509.93
------------------------------------------------------------------------------------------------------------
NAME GRENIER, WILLIAM J HIC U4510163202 ACNT 20164741-1 ICN 9681626103181
81993 1 A0429 RH 475.00 374.36 0.00 37.44 0.00 336.92
81994 3 A0425 RH 36.00 23.89 0.00 2.39 0.00 21.50
PT RESPONSIBILITY 39.83 CLAIM TOTALS 511.00 398.25 0.00 39.83 0.00 358.42
OTHER ADJ: 112.75,PR-45
TOTALS: # OF BILLED ALLOWED DEDUCT COINS TOTAL PROV PD PROV CHECK
CLAIMS AMT AMT AMT AMT RC-AMT AMT ADJ AMT AMT
2 1,317.20 1,035.66 0.00 167.31 168.79 868.35 112.75 868.35
The following definitions were found based on codes found in the file:
CO Contractual Obligations
PR Patient Responsibility
2 Coinsurance Amount
45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group
Codes PR or CO depending upon liability) .
�t CARMEL FIRE DEPARTMENT
.FG�.0 2 CIVIC SQUARE
CARMEL, IN 46032-2584
rr 111001p• (317) 571 2604 Federal ID#356000972
Patient Name: RAY, SHELLY
SHELLY RAY CARMEL FIRE DEPARTMENT
5601 STREAMSIDE DR 2 CIVIC SQUARE
INDIANAPOLIS , IN 46278-1961 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date Balance
THIS PORTION WITH YOUR PAYMENT 11/29/2016 806.20
Ticket# : 20164888:1 Patient ID Amount Paid
Date Of Service: 8/30/2016 990115015
DETACH HERE
WORKER'S COMPENSATION CLAIM. REFUND CIGNA HEALTH INSURANCE. REFUND $509.93
THANK YOU
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE $806.20
Pay online at www.govpaynet.com with PLC#7487 Run Number 20164888:1
Online Payment will charge a service fee.
Dateof Service DescriptionPatient Name Charges) 'Date
Charges
8/30/2016 *ADVANCED LIFE RAY, SHELLY $775.00
8/30/2016 *MILEAGE RAY, SHELLY $31.20
---------------------------------
Charge Total: $806.20
Payments
Paid By: CIGNA/ 182223 COMMERCIAL INSURANCE 10/04/16 ($509.93)
Paid By. CIGNA/ 182223 WRITE OFF-INSURANCE 10/04/16 ($168.79)
Paid By: CIGNA/ 182223 WRITE OFF 11/29/16 $168.79
Paid By: CIGNA/ 182223 REFUND 11/29/16 $509.93
BALANCE $806.20