HomeMy WebLinkAbout313794 07/18/2017 / §
�
.a 2 c = o
c / £ § 7 R
m 2 § 2
0
/ N @ 0
§ k $ / u
2
£ 2 ' 2 / c
LL �_ a §
C
R @ \ ƒ x
ui m Q m 2 0
R : § 0 2
k q ƒ
@
k § ƒ a)
| z
� z
0 _
L �
O 2
2 E c
w 22
� ƒ
crCE CL
\ \ k
� \ � �
k/
C 7 %
L Z / \
LU 7 E
Z 1
2 R \ CL
7 k
b U \ \
U Q5
U « ®F-4
(§
>
L
4
cli EL
JA-NiEs BRAINARD, MAYOR
July 10, 2017
David Grass
5404 CAYMAN DRIVE
CARMEL, IN 46033
RE: Account#20160322:1 D.O.S. 01/19/2016
Dear David Grass:
Enclosed you will find a refund check in the amount of$ 154.14.
On April 5, 2016 we received your payment for$ 404.14 Check#4846.
On June 30, 2017 Anthem Senior Advantage reprocessed your claim
Copay due is only$250.00
Issue refund of$154.14 the overpayment to the patient.
If you have any questions, please feel free to contact me at (317) 571-2604.
Sincerely,
Michelle T. Harrington
EMS Billing Administrator
CARMEL FmF. DEPARTMENT
STENTN A. COVTs HEADQUARTERS
Two Chic SOUARE. CARMEL. IN 46032 OFFICE 311.571.2600. FAX 317.571.2615
CAXWZ CARMEL FIRE DEPARTMENT
IFJD 2 CIVIC SQUARE
CARMEL, IN 46032-2584
Q' 1 (317) 571 2604 Federal ID#356000972
Patient Name: GRASS, DAVID E
DAVID GRASS CARMEL FIRE DEPARTMENT
5404 CAYMAN DR 2 CIVIC SQUARE
CARMEL, IN 46033 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/10/17 200500901
Ticket#: 20160322:1
Date of Service: 1/19/2016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESSED YOUR CLAIM COPAY$250.00. PATIENT PAID
$404.14-$250.00=$154.14 REFUND PATIENT OVERPAYMENT. THANK YOU
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE
Pay online at www.govpaynet.com with PLC#7487 Run Number 20160322:1
Online Payment will charge a service fee.
Da � S�r e.J des iptio� t � Patient lV me
x
t a Charge(s� Datei� i�en (
Charges
1/19/2016 "ADVANCED LIFE GRASS, DAVID E $575.00
1/19/2016 "MILEAGE GRASS, DAVID E $54.00
---------------------------------
Charge Total: $629.00
Payments
Paid By: Invoice 01/19/16 $629.00
Paid By: ANTHEM SENIOR ADVANTAGE/ BLUE SHIELD PAYMENT 03/02/16 ($35.48)
Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 03/02/16 ($189.38)
Paid By: GRASS, DAVID E Payment 04/05/16 ($404.14)
Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 06/30/17 ($192.46)
Paid By: ANTHEM SENIOR ADVANTAGE/ MEDICARE PAYMENT 06/30/17 ($186.54)
BALANCE $0.00
CAR-WI. CARMEL FIRE DEPARTMENT
F.+ D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
• (317) 571 2604 Federal ID#356000972
Patient Name: GRASS, DAVID E
DAVID GRASS CARMEL FIRE DEPARTMENT
5404 CAYMAN DR 2 CIVIC SQUARE
CARMEL, IN 46033 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID AMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/10/17 200500901
Ticket# : 20160322:1
Date of Service: 1/19/2016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESSED YOUR CLAIM COPAY$250.00. PATIENT PAID
$404.14- $250.00=$154.14 REFUND PATIENT OVERPAYMENT. THANK YOU
Paid By: ANTHEM SENIOR ADVANTAGE/ MEDICARE PAYMENT 06/30/17 $35.48
Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 06/30/17 $189.38
Paid By. ANTHEM SENIOR ADVANTAGE/ REFUND 06/30/17 $154.14
BALANCE $0.00