311944 05/30/2017 (9)
CITY OF CARMEL, INDIANA VENDOR: T356607
ONE CIVIC SQUARE DAVID J BUELT CHECK AMOUNT: $**"****590.87*
CARMEL, INDIANA 46032 6163 RUTHVEN DRIVE CHECK NUMBER: 311944
NOBLESVILLE IN 46062 CHECK DATE: 05/30/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 590.87 OTHER EXPENSES
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CITY RMEL
JANIEs BR.NINARD, MAYOR
May 8, 2017
David J. Buelt
6163 Ruthven Drive
Noblesville, IN 46062
RE: Account#20170594:1 D.O.S. 01/29/2017
Dear David Buelt:
Enclosed you will find a refund check in the amount of$ 590.87.
On April 7, 2017 we received your payment for$ 656.52.
On April 28, 2017 we received a payment from Cigna for $590.87.
Cigna reprocessed your claim. Copay due is only $65.65.
Issue refund of$590.87 the overpayment to the patient.
If you have any questions, please feel free to contact me at (317) 571-2604.
Sincerely,
z�4 a ",, �
Michelle T. Harrington
EMS Billing Administrator
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CARML CARMEL FIRE DEPARTMENT
g�p 2 CIVIC SQUARE
CARMEL, IN 46032-2584
CLAX1WP. (317) 571 2604 Federal ID# 356000972
Patient Name: BUELT, SHANNON
SHANNON BUELT CARMEL FIRE DEPARTMENT
6163 ruthven dr 2 CIVIC SQUARE
Noblesville, IN 46062 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 05/08/17 990116731
Ticket# : 20170594:1
Date of Service: 1/29/2017
DETACH HERE
04/07/2017 WE RECEIVED YOUR PAYMENT OF$656.52. CIGNA REPROCESSED YOUR CLAIM
AND PAID $590.87. CO PAY$65.65. OVERPAYMENT ISSUED TO THE PATIENT FOR$590.87.
THANK YOU
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE $0.00
Pay online at www.govpaynet.com with PLC#7487 Run Number 20170594:1
Online Payment will charge a service fee.
Date of Service '�Description Patient Name Charges) bate Payments)
Charges
1/29/2017 "ADVANCED LIFE BUELT, SHANNON $592.25
1/29/2017 *MILEAGE BUELT, SHANNON $64.27
---------------------------------
Charge Total: $656.52
Payments
Paid By: Invoice 01/29/17 $656.52
Paid By: BUELT, SHANNON Payment 04/07/17 ($656.52)
Paid By: BUELT, SHANNON COMMERCIAL INSURANCE 04/28/17 ($590.87)
Paid By: BUELT, SHANNON REFUND 05/08/17 $590.87
BALANCE $0.00
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DATE: 5/8/2017 835 Remittance Advice
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ELECTRONIC COMMERCE HEALTHCARE ORGA CITY OF CARMEL FIRE DEPARTMENTSUBMITTER #: OPTUM ACH CHK/REF#: 1926089712
868 CORPORATE WAY 2 CIVIC SQUARE PROV/NPI #: 356000972 DATE: 4/28/2017
WESTLAKE, OH 441451502 CARMEL, IN 460322584 TR SET: 000002552 AMT: 590.87
868 CORPORATE WAY 2 CIVIC SQUARE PAYER ID: OOOOECHOH
---------------------------------
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CHG CODE SERV DATE POS UNTS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC-AMT PROV PD
-------------------------------------------------------------------------------------------------------------------
NAME BUELT, SHANNON HIC 478686201 ACNT 20170594-1 ICN 1757497602
01/29/17 1 A0427 SH 592.25 592.25 0.00 59.22 0.00 533.03
01/29/17 1 A0425 SH 64.27 64.27 0.00 6.43 0.00 57.84
PT RESPONSIBILITY 65.65 CLAIM TOTALS 656.52 656.52 0.00 65.65 0.00 590.87
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----------- ---------
TOTALS: # OF BILLED ALLOWED DEDUCT COINS TOTAL PROV PD PROV CHECK
CLAIMS AMT AMT AMT AMT RC-AMT AMT ADJ AMT AMT
1 656.52 656.52 0.00 65.65 0.00 590.87 0.00 590.87
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The following definitions were found based on codes found in the file:
PR Patient Responsibility
2 Coinsurance Amount