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Home My WebLink About321765 02/13/18 r Cqq "y' ''• CITY OF CARMEL, INDIANA VENDOR: 372225 6 ONE CIVIC SQUARE OPTUM CHECK AMOUNT: S*******153.20* CARMEL, INDIANA 46032 75 REMITTANCE DRIVE CHECK NUMBER: 321765 SUITE 6019 CHECK DATE: 02/13/18 *ox CHICAGO IL 60675 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 153.20. OTHER EXPENSES ` Prescribed by State Board of Accounts City Form No.201(Rev.1995)' VOUCHER NO. WARRANT NO. - ALLOWED 20 ACCOUNTS PAYABLE VOUCHER Vendor# 372225 OPTUM IN SUM OF$ CITY OF CARMEL 75 REMITTANCE DRIVE An invoice or bill to be properly itemized must show:kind of service,where performed,dates service SUITE 6019 rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc. CHICAGO, IL 60675 Payee $153.20 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 $153.20 1 hereby certify that the attached invoice(s),or 2/5/18 0 $153.20 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, February 06,2018 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 __120 Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer i y. n 1. CITY; O ARMEL JAMES BRAINARD, MAYOR January 30, 2018 Optum 75 Remittance Drive Suite 6019 Chicago, IL 60675 RE : OVERPAYMENT RUN#2017-00002584 :1 Noel Merrick Date of Service 05/11/2017 Optum Overpayment: Overpayment Refund$153.20 enclosed for AARP Medicare Complete. AARP/Medicare Health insurance paid$153.20 on 06/20/2017. This was a Worker's Compensation incident. 01/17/2018 Church Mutual Insurance paid the claim in full. Created overpayment of$153.20. Refund to be sent to Optum AARP/Medicare Complete If you have any questions, please feel free to contact me at (317) 571-2604. Sincerely, Michelle T. Harrington EMS Billing Administrator CARMEL FIRE DEPARTMENT STEVEN A. COUTS HEADQUARTERS TWO CIVIC SQUARE, CARMEL, IN 46032 OFFIcE 317.571.2600, FAx 317.571.2615 MN1102- ®P 1 U 1'i o 11000 00300 circle Eden Prairie,MN 55344 �Iil��lllllilll�III�I�nI11IIlIII�II�I��I��IIIIIIrIIrrII�I�I 44-1-1 Attn:Billing Department Carmel Fire Dept Ambulance Svc 2 Civic Sq Carmel IN 46032-2584 January 24,2018 RE: Patient: Noel L Merrick DOB 3/13/34 _Date of Service: 5/11/17 Date of Injury: 5/2/2017 File#: 31871510 Provider acct#: 2017-00002584-1 Dear Carmel Fire Dept Ambulance Svc, Optum has been retained by United Healthcare to pursue a recovery for medical benefits that have been --paid by-them-on behalf-of Noel L_Merrick, rho received treatment at-your facility on the above referenced date.We have learned that this care was due to a Workers'Compensation incident. U n ited Healthcare was billed and paid Carmel Fire Dept Ambulance Svc for its charges.We spoke with Church Mutual Insurance Co which confirmed a claim was accepted. The claims should have been presented to and paid by: Church Mutual Insurance Co PO BOX 342 MERRILL,WI 54452 WC Claim Number#: 131696900002 WC Phone#: 800.554.2642 ext. 5875 United Healthcare is entitled to a refund of the duplicate payment, once the workers'compensation insurer has paid your facility. Please issue your check in the amount of$153.20, payable to United Healthcare and send it to the following address: Optum 75 Remittance Dr Suite 6019 Chicago, IL 60675 Any communication concerning a dispute about this settlement, including an instrument tendered as full satisfaction of the recovery interest where the tendered amount differs from Optum's last demand or the G4TX812400000440101000000000000000 � CITY OF CARMEL FIRE DEPT ' 2 CIVIC SQUARE CARMEL, IN 46032-2584 (317) 5712604 Federal ID#356000972 Patient Name: MERRICK, NOEL L NOEL MERRICK CITY OF CARMEL FIRE DEPT 811 PAWNEE DR 2 CIVIC SQUARE CARMEL, IN 46032 CARMEL, IN 46032-2584 TO ASSURE PROPER CREDIT, RETURN Statement Date I Patient ID JAMOUNT PAID THIS PORTION WITH YOUR PAYMENT 01/30/18 990117924 Ticket# : 2017-00002584:1 Date of Service: 5/11/2017 DETACH HERE WORKER'S COMPENSATION INCIDENT. REFUND HEALTH INSURANCE $153..20 MAKE CHECKS PAYABLE TO: CITY OF CARMEL FIRE DEPT BALANCE Pay online at www.govpaynet.com with PLC#7487 Run Number 2017-00002584 Online Payment will charge a service fee. Pa ment s Date of Service Descnpt�o Patient NameG Chargme(s) Date Charges 5/11/2017 *BASIC LIFE SUP MERRICK, NOEL L $489.25 5/11/2017 *MILEAGE MERRICK, NOEL L $23.48 --------------------------------- Charge Total: $512.73 Payments Paid By. Invoice 05/11/17 $512.73 Paid By. AARP/MEDICARE COMPLETE ASSIGNMENT MEDICARE 06/20/17 ($159.53) Paid By. AARP/MEDICARE COMPLETE MEDICARE PAYMENT 06/20/17 ($153.20) Paid By. AARP/MEDICARE COMPLETE ASSIGNMENT MEDICARE 06/20/17 $159.53 Paid By. CHURCH MUTUAL INSURANCE COMMERCIAL INSURANCE 01/17/18 ($512.73) Paid By. AARP/MEDICARE COMPLETE REFUND 01/30/18 $153.20 BALANCE $0.00