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Home My WebLink About319150 11/30/2017 ♦y�r C4q�� % J CITY OF CARMEL, INDIANA VENDOR: 372073-.. CHECK AMOUNT: $*******406.67* .�_ � ,• ONE CIVIC SQUARE MDWISE, INC. CARMEL, INDIANA 46032. P.O.BOX 775166 CHECK NUMBER: 319150 CHICAGO IL 60677-5166 CHECK DATE: 11/30/17 DEPARTMENT _ ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION .102 5023990 406.67 OTHER EXPENSES VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995) Vendor# 372073 ALLOWED 20 ACCOUNTS PAYABLE VOUCHER MDWISE, INC. IN SUM OF$ CITY OF CARMEL P.O. BOX 775166 An invoice or bill to be properly itemized must show:kind of service,where performed,dates service rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc. CHICAGO, IL 60677-5166 Payee $406.67 Purchase Order# ON ACCOUNT OF APPROPRIATION FOR Carmel Fire Terms Date Due PO# ACCT# DATE INVOICE# DESCRIPTION DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT 0 50-239.90 $406.67 1 hereby certify that the attached invoice(s),or 11/22/17 0 $406.67 1120 102 1120 102 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 Tuesday, November 28,2017 David Haboush Fire Chief I hereby certify that the attached invoice(s),or bill(s),is(are)true and correct and I have audited same in accordance with IC 5-11-10-1.6 _ 20— Cost 20Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer i II ti t CITY O ARIVIEL JAMES BRAINARD, MAYOR November 21, 2017 MDwise Inc PO Box 775166 Chicago, IL 60677-5166 RE : OVERPAYMENT RUN#20170752 :1 Sakyra Hyter Date of Service 02/06/2017 Dear Claims Department: Overpayment,:Refund $406.67 is enclosed for MDwise Inc. Duplicate EFT payments were received from MDwise HIP on 08/10/2017 for$407.71 And another EFT payment$406.67 this created overpayment._ Refund to be sent to MDwise Inc. If you have any questions,please feel free to contact me at (317) 571-2604. .Sincerely, Michelle T. Harrington EMS Billing Administrator CARMEL FIRE DEPARTIVIENT STEVEN A. COUTS HEADQUARTERS TWO CIVIC SQUARE, CARMEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2617 HDWse RECEIVED NOV f November 10, 2017 CITY OF CARMEL FIRE DEPARTMENT 2 CIVIC SQ CARMEL, IN 46032 Refund Request - MEMBER NAME: Sakyra Hyter CLAIM #: 2017111T2156800 DATE(S) OF SERVICE: 2/06/2017 ACCOUNT #: -201707521 Dear Provider: Upon review of the above listed claim it has been determined that a refund is now due. The reason for this refund request is: ❑ Claim was overpaid D Member was not eligible on this date of service D Member is involved in a subrogation case for whicl Nave agreed to a retraction/refund D, Member has primary coverage on this date of se- %< Other: duplicate payment A refund in the amount of$406.67 is being requested at this time. The check shOUld be made payable and mailed to: MDwise,Inc. P.O.Box 775166 Chicago,IL 60677-5166 Please include a copy of this letter with the check. If a refund check is not received within 90 days,the amount of the payment will be recouped from future payments you may receive. Should you have any further questions, please call 1-(800) 356-1204. Sincerely. MDwise, Inc. 8 CIN OF CARMEL FIRE DEPARTMENT EOP Number: 155182 MDwise Healthy Indiana Plan 2 CIVIC SQ PO Box 331609 CARMEL,IN 46032 EFT:Date: 811 01571 MDwise Corpus Christi,TX 78463-1609 Date: 08!10/2017 Questions? Page 3 Call 800-356-1204 or 317-630-2831 in the Indianapolis area. Explanation of Payment Claim Number Data of Service Procedure Chargo Allow DedlCoin Copay Adjust- Coda Withhold NelAmount Prov Pay COB Refund Claim Paid ACT#:2017-000015111 2D17132T1Bfi96.00 031712017�401712017 A0429 Sa8925 50.00 $0100 SO.00 $489.25 AMBO.WEO $0.00; $0.00 SD.00 50.00 $0.00 50.00 2017132TIO696M =742017.0311712017 AO-125 . 560.56 $0.00 $0,00 .$0.00 $0.00 X208 50.001„. $0.00 50,00 SO.DO $0.00 $0,00 . Interest$0.00� S549.B1 _ $0.00 50.00 $0.00 $489.M $0.00; $0.00 $0.00 $0.00 $0.00 $0.00 f Summary:HYTIK SAKYRA ACT#:201707521 - Member ID:101780303699 ,J/ 2017099TO24DGW 020W2017-02'06'2017 A0427 559225, 5406-67 50.00 WOO $185.58 ONUG SO.OD S406.67' SO.00 50.00 50.00 5406.67 Y 201709970240600 02(0G/20I7-0206'2017 A0426 '596.41 50.00 80.00 $0.00 $0.00 X208 $0.00 $0.00 SOAO SO.0D 50.00 50.00 Interest:$1.04 $688.66 $406,67 $0.00 $0.00 $i asso $moo $408,87 $0.00 50.00 moo $406.67 Summary:HYTER,SAKYRA ACTH:201707521 Member 10:101780347699 201 7111 721 5 6800 02iM2017-WDW2017 A0427 $592.25 S406.67 50.00 50.00 5185,58 ONMC $0.00 S406,67 50.00 10.00 SD.00 S406.67 201711172156800 024 6/2017-02106/2017 A0425 598.41 SO.00 SO.00 50.00 50.00 X208 $0.00 50.00 90.00 SO.00 $0.00 $0.00 Intarusk S0.g0 0686.66 $406.67 $0.00 $0.00 5189911 $0A0 5406.67 $0.00 30.00 $0.00 $406.67 ACT#:20170000/8201 � - - 2017138T2205400 044=017-04/03(2017 A0429 Si89.2S SO.00 SO.00 $0.00 $0.00 AM9D 50.00' SO.DD SO.OD S0.00 $0,0D $0.00 201713872205400 04ON2017-04+03!2017 AD425 $12.36 $0.00 50.00 $0.00 $0.00 X208 50.00 50.00 50.00 50.00 SOAD 50.00 Interest$0.00 5501.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10.00 $0.00 $0.00 AGTk 2017000032071 2017174T19056R 06 Ca2017-MOW2017 A0427 559225 S406.67 50.00 50.00 S185M ONMC S0.0D $406.67 50.00 $0,00 $0.00 S4D8.67 - 2017174TI905600 Oft+M017-MIOEV2017 A0425 982.81 $0.00 $0.00 S0.00 SO.00 X208 $0.00 $0.00 SMOD $0.00 50.00 $0.00 Interest$0.20 $875.08 $406.67 $0.00 $0.00 St sso $0.00 $406.67 - $0.00 $0.00 50.00 5406.67 33,103.80 $1,220.01 $0.00 $0.00 111,049.99 $0.00 S1,2200I 50.00 $0.00 $MOO $11220.01 . Code Reference Description ` AMBD CLAIMS DENIED PER PRUDENT LAY PERSON REVIEW ONMC PROCESSED IN ACCORDANCE WITHOUT OF NETWORK REIMBURSEMENT RULES. SERVICES ONMC WITH NOASSIGNED FEE OR WHICH ARE CONSIDERED INCLUSIVEIPACKAGED Will RESULT ONMC IN$0.00 PAYMENT WEO, PLEASE SUBMIT COPY OF PRIMARY INSURANCE EXPLANATION.OF PAYMENT X208 PER MEDICARE GUIDELINES,THE HCPCS CODE IS IDENTIFIED ASAN AMBULANCE CODE X208 AND REQUIRES AN AMBULANCE MODIFIER APPENDED.