313838 07/18/2017 CITY OF CARMEL, INDIANA VENDOR: 371807
ONE CIVIC SQUARE CAROL METCALF CHECK AMOUNT: 8"""""""204.82"
_? r CARMEL, INDIANA 46032 9306 WEST POINTE PLACE CHECK NUMBER: 313838
INDIANAPOLIS IN 46268 CHECK DATE: 07/18/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 204.82 OTHER EXPENSES
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JA.NiEs BRAINARD, N'LAYOR
July 10, 2017
Carol Metcalf
9306 WEST POINT PLACE
INDIANAPOLIS, IN 46268
RE: Account#20160283:1 D.O.S. 01/17/2016
Dear Carol Metcalf:
Enclosed you will find a refund check in the amount of$ 204.82.
On May 3, 2016 we received your payment for$ 462.06 Check#7980.
On June 30, 2017 Anthem Senior Advantage reprocessed your claim
Copay due is $257.24.
Issue refund of$204.82 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 F[RE DF.Pm,,nu:NT
STE\EN A. COCTS HEADQ(- R1 F ,
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CA M- 14 CARMEL FIRE DEPARTMENT
Fp .D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
[7.�1�'TWP• (317) 5712604 Federal ID#356000972
Patient Name: METCALF, CAROL A
CAROL METCALF CARMEL FIRE DEPARTMENT
9306 WEST POINT PLACE 2 CIVIC SQUARE
INDIANAPOLIS , IN 46268 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/10/17 990112816
Ticket# : 20160283:1
Date of Service: 1/1712016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESSED YOUR CLAIM. CLAIM APPLIED OVERPAYMENT
IS $204.82 WILL BE SENT TO PAITENT.THANK YOU
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE
Pay online at www.govpaynet.com with PLC#7487 Run Number 20160283:1
Online Payment will charge a service fee.
a,f
a t e r pti nPentlam� `� � .. h Date ,
Charges
1/17/2016 *ADVANCED LIFE METCALF, CAROL A $575.00
1/17/2016 *MILEAGE METCALF, CAROL A $100.80
---------------------------------
Charge Total: $675.80
Payments
Paid By. Invoice 01/17/16 $675.80
Paid By: ANTHEM SENIOR ADVANTAGE ASSIGNMENT MEDICARE 03/17/16 ($213.74)
Paid By. METCALF, CAROL A Payment 05/03/16 ($462.06)
Paid By: ANTHEM SENIOR ADVANTAGE ASSIGNMENT MEDICARE 06/30/17 ($217.83)
Paid By: ANTHEM SENIOR ADVANTAGE ASSIGNMENT MEDICARE 06/30/17 $213.74
Paid By: ANTHEM SENIOR ADVANTAGE MEDICARE PAYMENT 06/30/17 ($200.73)
BALANCE $0.00
CAI, CARMEL FIRE DEPARTMENT
ZAP D 2 CIVIC SQUARE
CGA�'i�VP. CARMEL, IN 46032-2584
(317) 5712604 Federal ID#356000972
Patient Name: METCALF, CAROL A
CAROL METCALF CARMEL FIRE DEPARTMENT
9306 WEST POINT PLACE 2 CIVIC SQUARE
INDIANAPOLIS , IN 46268 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID AMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/10/17
Ticket# : 20160283:1 990112816
Date of Service: 1/17/2016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESSED YOUR CLAIM. CLAIM APPLIED OVERPAYMENT
IS $204.82 WILL BE SENT TO PAITENT. THANK YOU
Paid By: ANTHEM SENIOR ADVANTAGE MEDICARE PAYMENT
06/30/17 ..
$0.00
Paid By: METCALF, CAROL A REFUND 06/30/17
$204.82
BALANCE $0.00