HomeMy WebLinkAbout313486 7/10/2017 CITY OF CARMEL, INDIANA VENDOR: 371761
ONE CIVIC SQUARE UNITED OF OMAHA LIFE INSURANCE CBHECK AMOUNT: $....****95.33*
CARMEL, INDIANA 46032 S MEDICARE SUPPLEMENT CLAIMS DEPT CHECK NUMBER: 313486
�M. OMAHA NE 68175 CHECK DATE: 07/10/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 20171142 95.33 OTHER EXPENSES
VOUCHER NO. WARRANT NO.
Z -� .ALLOWED 20
IN SUM OF $
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO#or INVOICE NO. ACCT#/TITLE AMOUNT I herebycertify that the attached invoice(s , or
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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
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20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
CIT . EL
JAMES BRAINARD, NIA:vOR
July 6, 2017
United of Omaha Life Insurance Company
8 Medicare Supplement Claims Department
Mutual of Omaha Plaza
Omaha,NE 68175
RE : OVERPAYMENT RUN # 20171142 :1 Robert R. Johns
Date of Service 02/24/2017
Dear Claims Department:
Refund for$95.33 will be issued to United of Omaha Life Insurance Company.
A check was received from UNITED OF OMAHA on 05/12/2017 for$95.33.
On 05/16/2017 CONSTITUTIONAL LIFE INSURANCE sent a check for $95.33
this created overpayment.
Refund to be sent to United of Omaha Life Insurance Company.
If you have any questions, please feel free to contact me at(317) 571-2604.
Sincerely,
Michelle T. Harrington
EMS Billing Administrator
CARMEL Ftt:r_ DEPARTMENT
STI%-EN A. Cou-rs HE DQI-ARTE:Rs
Tvxo Cn-rc SorARE. CAIMFI. IN +662 OFFICE '17.�71.2000. Fv.x i17.571.261�
C,RM CARMEL FIRE DEPARTMENT
F'4A D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
Q•AY'1' (317) 571 2604 Federal ID#356000972
Patient Name: JOHNS, ROBERT R
ROBERT JOHNS CARMEL FIRE DEPARTMENT
9624 WILD CHERRY LANE 2 CIVIC SQUARE
INDIANAPOLIS , IN 46280 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/06/17 990117103
Ticket# : 20171142:1
Date of Service: 2/24/2017
DETACH HERE
OVERPAYMENT $95.33 REFUND CHECK TO UNITED OF OMAHA LIFE INSURANCE.THANK YOU
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE $0:00
Pay online at www.govpaynet.com with PLC#7487 Run Number 20171142:1
Online Payment will charge a service fee.
VV
oSencD�cption atien Name* f¥ yC�ar9e�s) e ,`t
Charges
2/24/2017 *ADVANCED LIFE JOHNS, ROBERT R $592.25
2/24/2017 *MILEAGE JOHNS, ROBERT R $118.66
---------------------------------
Charge Total: $710.91
Payments
Paid By. Invoice 02/24/17 $710.91
Paid By: MEDICARE PART B MEDICARE PAYMENT 04/27/17 ($373.69)
Paid By: MEDICARE PART B) ASSIGNMENT MEDICARE 04/27/17 ($241.89)
Paid By: dAH� 6 COMMERCIAL INSURANCE 05/12/17 ($95.33)
Paid By: CONSTITUTIONAL LIFE COMMERCIAL INSURANCE 05/16/17 ($95.33)
Paid By: MUTUAL OF OMAHA REFUND 07/06/17 $95.33
BALANCE $0.00
UNITED Of OMAHA LIFE INSURANCE COMPANY
3300 Mutual of Omaha Plaza
Omaha,NE 68175
�Qmap� mutualofomaha.com
June 27, 2017
CITY OF CARMEL FIRE DEP
2 CIVIC SQ
CARMEL IN 46032-2584
Claim Number: 584402756000
Policy Number: 851658-90
Patient: Robert R. Johns
Date of Birth: 07/09/1938
Patient Account: 20171142-1
Date of Service From: 02-24-17
Date of Service To: 02-24-17
Our Draft Number: 83789834
Refund Amount Due: $95.33
Audit Number: 009
Attention: Patient Accounts
Based on information we received the benefits were incorrectly considered resulting in the above
date(s)of service being overpaid.
due to payment from med sup policy by Constitutional life
At this time we are requesting a refund of$95.33. Please make your check payable to United of
Omaha Life Insurance Company and mail your check to the following address:
United of Omaha Life Insurance Company
8 Medicare Supplement Claims Department
Mutual of Omaha Plaza
Omaha NE 68175
We are unable to apply this overpayment from any future benefits due.
ECSM-Pl70627080013000523
020200000000000000