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Home My WebLink About306013 ' VOUCHER NO. WARRANT NO. ALLOWED 20 SIN SUM OF $ 3 i 5 ON ACCOUNT OF APPROPRIATION FOR Board Members o PT.# INVOICE NO. ACCT#!TITLE AMOUNT I hereby certify that the attached invoice(s), or n bill(s) is (are) true and correct and that the materials or services itemized thereon for ti which charge is made were ordered and } received except j a I 9a Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund CITY EL J,"iEs BRAINA ), KWOR December 5, 2016 GREENSBORO SMALL GROUP P O BOX 740800 ATLANTA, GA 30374-0800 RE: Ticket#20164845:1 D.O.S. 08/28/2016 KAYLA WYATT $600.20 - $83.87=$516.33 Dear GREENSBORO SMALL GROUP Overpayment, Enclosed you will find a refund check in the amount of$516.33. We received your payment on October 31, 2016 for 600.20. Medicare is primary payment received $328.76 Greensboro Small Group is the secondary insurance provider- amount due $83.87. Overpayment invoice—refund issued to Greensboro Small Group Insurance for$516.33. If you have any questions, please feel free to contact me at (317) 571-2604. Sincerely, Michelle T. Harrington Billing Administrator CARMEL Ftm:: DEPAIMIEN-1 STEVEN A. CouT:s HE11:)Q1'AR1FRs T—, (- -c Cnrr..ov CkTINwr TN 217 X71 ')(,Of) Far X17 X71 ')(,1:; �t CARMEL FIRE DEPARTMENT Fb .D 2 CIVIC SQUARE CARMEL, IN 46032-2584 ��&�- (317) 571 2604 Federal ID#356000972 Patient Name: WYATT, KAYLA M KAYLA WYATT CARMEL FIRE DEPARTMENT 1264 GOLFVIEW DR APT A 2 CIVIC SQUARE CARMEL , IN 46032 CARMEL, IN 46032-2584 TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID JAMOUNT PAID THIS PORTION WITH YOUR PAYMENT 12/05/16 990114965 Ticket# : 20164845:1 Date of Service: 8/28/2016 DETACH HERE MEDICARE PAID ON 09/29/2016 . UHC IS THE SECONDARY PAID AS PRIMARY IN ERROR. REFUND DUE TO UHC THE AMOUNT OF $516.33. SUBTRACT$83.87 UHC 2NDARY PAYMENT. THANK YOU MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE ' Pay online at www.govpaynet.com with PLC#7487 Run Number 20164845:1 Online Payment will charge a service fee. Date f}SerWb.escription � `iPatient IamegCharge(s) Date a est s r &v .:�{—. 'Y�Ail -�g -"�.`0,._rA��S=.c...dr Charges 8/28/2016 *ADVANCED LIFE WYATT, KAYLA M $575.00 8/28/2016 "MILEAGE WYATT, KAYLA M $25.20 --------------------------------- Charge Total: $600.20 Payments Paid By: Invoice 08/28/16 $600.20 Paid By: MEDICARE PART B MEDICARE PAYMENT 09/29/16 ($328.76) Paid By: MEDICARE PART B ASSIGNMENT MEDICARE 09/29/16 ($187.57) Paid By: UHC NEW BUSINESS COMMERCIAL INSURANCE 10/31/16 ($600.20) Paid By: UHC NEW BUSINESS REFUND 12/05/16 $516.33 BALANCE $0.00 WPS GHA - MAC J8 IN PART B P.O. BOX 8580 REMITTANCE MADISON, WI 537080914 NOTICE PAYER BUSINESS CONTACT INFORMATION: WPS GHA - MAC J8 IN PART B TELEPHONE: 8662347331 PAYER TECHNICAL CONTACT INFORMATION: EDI HOTLINE TELEPHONE: 8662347331 URL: WWW.WPSMEDICARE.COM CITY OF CARMEL NPI #: 1154325579 2 CIVIC SQ DATE: 09/29/2016 CARMEL, IN 460322584 CHECK/EFT #: 886063698 PAGE #: 1 REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC-AMT PROV PD NAME WYATT, KAYLA HIC 308115406A ACNT 20164845-1 ICN 1816259722760 ASG Y MOA MA01 MA07 1154325579 0828 082816 41 1 A0427 SH 575.00 404.14 0.00 80.83 CO-45 170.86 316.84 CO-253 6.47 1154325579 0828 082816 41 2.1 A0425 SH 25.20 15.20 0.00 3.04 CO-45 10.00 11.92 CO-253 0.24 PT RESP 83.87 CLAIM TOTALS 600.20 419.34 0.00 83.87 187.57 328.76 ADJ TO TOTALS: PREV PD INTEREST 0.00 LATE FILING CHARGE 0.00 NET 328.76 CLAIM INFORMATION FORWARDED TO: INDIANA OFFICE MEDICAID POLICY I°age M unitedWalthwrc Insurance Company GREENS 0140 PC)BM 740800 gtALLGF IinitEdHealthe< re ATLANTA-GA 303-,,148010 f October 25,2016 Claim Information Patient: Kayla Wyatt Patient Acct#: 201648451 Date of Service: 08128;2018 3GOC ETPUA1001005.03233.01 Provider. 0-im-0 Fie DeptAmbularice CARMEL FIRE DEPT AMBULANCE SV SV _ __-- 2 CIVIC SQ Claim ID: XXXXX84441CW237822 CARMEL W 46032.2584 Claim#: 6176764821 Member. Brian Wyatt MamberQ S XXXXX8444 Group: MdiE MY TOCL$Bd3R Dear Camlei Fire Dept Ambulance Sv. CO INC Group#: GA41-10528AP.11004 Letter la Dip-1-006 We make every effort to process cla ms accurately,but sometimes e Luis uccut.'v'vd ut'v:p&d yvu Off a claim for Kayla Wyatt and need a refund. Please repay us$600 20 within 45 days of the date on tn,s letter. Thank you and we apo?et ize for any inconvenience this causes you Claim overpayment details: • Reason for overpayment: We paid ico much on Inc coinsurance amount. Tine patient has another health plan that processes claims first. • Check date: 10!21!2016 • Check number: QC62831760 s 1 • Amount of check sent to you.5600.20 (This amount may include ether claim payments.) • Charges submitted.$600.20 1 • Amount that should have been pad for this claim:$0.00 j • Correct coinsurance amount allowed: 50.00 • Patient responsibility for this claim:$600.20 k Mail your payment and this letter to: GREENSBORO SMALL GROUP PO BOX 740800 ' r ATLANTA, GA 30374-0600 We suggest you keep a copy for your records. ,f fi H you don't agree with this overpayment and you are part of our physician and health care professional network, please refer to the Administrative Guide or your participation agreement for further review options. If the overpayment identified in this letter requires revision of the benefit doterminaton, well send a corrected Explanation of Benefits(EOB) to the member and a corrected Provider Remittance Admce to you. Any revised EOB will include informat;on about the members rights under ERISA, if applicable, You may appeal the reused benefit determination on the members behalf with their signed authorization. You may also have additional rights under state law. Ij If you have quest!ons about this letter, please call 1.877.842.3210. s CFD