HomeMy WebLinkAbout319797 12/21/2017 CITY OF CARMEL, INDIANA VENDOR: 372121
a; ONE CIVIC SQUARE BLUE CROSS BLUESHIELD OF ILLINOIS CHECK AMOUNT: $....***529.78*
x CARMEL, INDIANA 46032 25718 NETWORK PLACE CHECK NUMBER: 319797
CHICAGO IL 60673-1257 CHECK DATE: 12/21/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 0 529.78 OTHER EXPENSES
`s:
VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201 (Rev.1995)
ALLOWED 20
Vendor# 372121 ACCOUNTS PAYABLE VOUCHER
BLUE CROSS BLUESHIELD OF ILLINOIS IN SUM OF$ CITY OF CARMEL
25718 NETWORK PLACE 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 60673-1257
Payee
$529.78
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 $529.78 1 hereby certify that the attached invoice(s),or 12/12/17 0 $529.78
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
Wednesday, December 13,2017
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 distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer
CIEL
JAMES BmNARD, MAYOR
December 8, 2017
B1ueCross BlueShield of Illinois
25718 Network Place
Chicago, IL 60673-1257
RE : OVERPAYMENT RUN #2017-00005796 :1 John Bretz
Date of Service 10/12/2017
Dear Claims Department:
Overpayment Refund$529.78 is enclosed for B1ueCross BlueShield of Illinois.
Claim was processed as primary by B1ueCross BlueShield in error on 11/09/2017
check received for $612.85.
B1ueCross BlueShield of Illinois is the secondary insurance -amount due is $83.07.
BCBS of IL check$612.85-$83.07=$529.78 refund.
Medicare paid claim as primary on 11/13/2017 $325.64.
Refund to be sent to B1ueCross BlueShield of Illinois.
If you have any questions, please feel free to contact me at (317) 571-2604.
Sincerely,
Michelle T. Harrington
EMS Billing Administrator
CARIVIEL FIRE DEPARTiIIENT
STEVEN A. CouTS HEADQUARTERS
TWO CIVIC SQUARE, CARAIEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615
B1ueCross B1ueShield Please submit refunds to:
►•� of Illinois Blue Cross and Blue Shield'of Illinois.
25718 Network Place,Chicago, IL 60673-1257
Provider Refund Form
Provider Information:
Address'.{ '2— i v J 1
Contact=Name i4CA 0\
Phone Number
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NPI Number
Refund Information:
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GROUP#FROM PCs MEMBER I.D.FROM P(S ADM DATE CLAIM/DCN#
4 PATIENT'S NAME PROVIDER PATIENT# IETTER REFERENCE# REFUND AMOUNT
REASON/REMARKS
GROUP#FROM PCS MEMBER I.D.FROM PCs ADM DATE CIAIM/DCN#
PATIENT'S NAME P�T# LETTER REFERENCE# REFUND AMOUNT:
5
REASON/REMARKS
GROUP#FROM PCS MEMBER I.D.FROM PCS ADM DATE (LAIM/D(N#
PATIENT'S NAME PROVIDER PATIENT# IETTER REFERENCE# REFUND NAOUNT:
6
REASON/REMARKS
SIGNATURE DATE CHECK NUMBER CHECK DATE
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association 03054.1211
BluecrossBlueShieldottltinois PROVIDER CLAIM SUMMARY
P.O.BOX 7344
Ghkagd,IL 60680-7344 DATE: 10/30/17
PROVIDER NUMBER: llS4325579 ='
FOR AADC 460 CHECK NUMBER: 80833266
5754 1 AB 0.403 25 TAX IDENTIFICATION NUMBER: 356000972
CITY OF CARMEL Visit )yivw.bcbsi1.comjEr&y1dcP, 8
2 CIVIC;SQUARE for the latest nears and updates on matters that impact you Q
CARMEL IN 46032-2584 ��
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ANY_ MESSAGES WILL APPEAR ON PAGE 1
PATIENT JOHN BRETZ
PERF PRV: 1154325579 IDENTIFICATION NO: 131651-WVE843150130
CLAIM NO: 00007303573K4680X PATIENT NO: 2017-00005796-1
FROM / TO PROC AMOUNT AMOUNT DEDUCTIONS/OTHER SERVICES
DATES PSX* PAY CODE BILLED PAID INELIGIBLE NOT COVERED
10/12-40/12/17 05 NOP A0429 489.25 489.25 0.00 0.00
10/12-10/12/17 05 NOP A0425 123.60 123.60 0.00 0.00
612.85 612.85 0.00 0.00
AMOUNT PAID TO PROVIDER FOR THIS CLAIM: $612.65 MEDICARE CROSSOVER CLAIM
---------------------------------------------------------------------------------------------------------------
AMOUNT BILLED: $612,85 AMOUNT OF SERVICES NOT COVERED: 50.00
AMOUNT PAID TO PROVIDER: $612.85 AMOUNT PREVIOUSLY PAID: 50.00
AMOUNT PAID TO .SUBSCRIBER: $0.00 NUMBER OF CLAIMS: 1
RECOUPMENT AMOUNT: $0.00 NET AMOUNT PAID TO PROVIDER: $612.85
I **PLACE OF SERVICE (PS)
05. OTHER.
MESSAGES:
NO MESSAGES FOR THIS DOCUMENT
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5fxtronic CWim •- Invoice Invoice 10/12/2017 10/12/2017 10/172017 S612.85 Posted
i td Invoice Invoice Reversal - .10/12/2017 10/122017 10/27%2017 (5612.85) Reversal of Posted, Posted
INVOICE-30 day Basic Invoice
J Invoice lnvaice 10/1212017 10/12/2017 10/27/2017 5612.85 Posted
INVOICE-60 day.Basic lnwicc-i _
-- p Payment - BLUE SHIELD PAl'M ANTHEM BLUE CRC 1L13(2017 iv9r2017
1119 M-17 (5(512.85)50.00/50.O1 CK 0080833266 Posted
ID!VOICE i90day-Basclnwice Ip / Payment MEDICARE PAVMEf MEDICARE PART B 11/1320/7 11/132017 11114/2017 (5325.64)/(583.07)/5( 836709456 CO253,CO45,MA01 Posted
' Writeoff ASSIGNMENT MED. MEDICARE PART B 11!132017 1113/2017 11/14/2017 (S2O4.14) 886709456 CO253,CO45,MA01 Posted
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Notes' Credit REFUND ANTHEM BLUE CRC 1218?2017 1111812017 12/8/2017 $529.78 131651-WVEB4315i BLUE CROSS BLUEPosted
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