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Home My WebLink About323888 04/06/18 1°.CgyA ?6 � CITY OF CARMEL, INDIANA VENDOR: 366802 it ONE CIVIC SQUARE WPS GHA MEDCARE PROVIDER ENROLAtIE1919 AMOUNT: $*******620.72* q CARMEL, INDIANA 46032 PO BOX 8064 CHECK NUMBER: 323888 . MADISON WI 53708-8064 CHECK DATE: 04/06/18 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 201700059243 283.35 OTHER EXPENSES 102 5023990 201800001441 337.37 OTHER EXPENSES i,. VOUCHER NO. WARRANT. NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995) Vendor# 366802 ALLOWED 20 ACCOUNTS PAYABLE VOUCHER WPS GHA MEDCARE PROVIDER ENROLLMENT IN SUM OF$ CITY OF CARMEL PO BOX 8064 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. MADISON, WI 53708-8064 Payee $620.72 ON ACCOUNT OF APPROPRIATION FOR Purchase Order# 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 2018-00000144:1 50-239.90 $337.37 1 hereby certify that the attached invoice(s),or 3/29/18 2018-00000144:1 $337.37 1120 102 1120 102 2017-00005924:3 50-239.90 $283.35 bill(s)is(are)true and correct and that the 3/29/18 2017-00005924:3 $283.35 1120 1 102 1 materials or services itemized thereon for 1120 102 which charge is made were ordered and received except Thursday, March 29,2018 U,ar David Haboush Fire Chief 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 CITY CSF ARMEL JAMES BRAINARD, MAYOR March 26, 2018 WPS GOVERNMENT HEALTH ADMINISTRATORS PAYMENT RECOVERY P.O. BOX 8064 . MADISON, WI 53708-8064 RE : Brian Immel 2017-00005924:3 $283.35 Dear Sir/Madam: Enclosed you will find a check in the amount of$283.35. Medicare claim paid on 02/07/2018 and Geico Auto Insurance paid this claim on 03/08/2018. Duplicate payment received-created an overpayment of$283.35 Refund Health Insurance WPS Medicare. If you have any questions, please feel free to contact me at(317) 571-2604. Sincerely, Michelle T. Harrington Billing Administrator CARMEL FIU DETARTMEN' STEVEN A. Coufs HEADQUARTERS TWO CIVIC SQUARE, CARMEL, IN 46032 OFFICE 317,571.2600, FAx 317.571.2615 MEDICARE Part.B CENTERS FOR MEDICARE&.MEi"1Rd'AID SERVICES Letter Number: 23265667 Date: 03/13/2018 CITY OF CARMEL 2 CIVIC SQUARE CARMEL, IN 460322584 INITIAL REQUEST ___R E_ Medicare_Overpayment- --- -- Overpayment Overpayment Amount: $283.35 Outstanding Balance: $283.35 Provider Number: 317470-1154325579 Dear Sir/Madam, This is to let you know that you have received a Medicare payment in error, which has resulted in an overpayment to you of$283.35. The attached enclosure explains how this happened. Why you are responsible: You are responsible for following correct Medicare filing procedures and must use care when billing and accepting payment. You are responsible for repayment in this matter based upon one or both of the following criteria: 1. You billed and/or received payment for services for which you should have known you were not entitled to receive payment. Therefore, you are not without fault and are responsible for repaying the overpayment amount. 2_ Yost received—overpayments resuJ_ting_from_retr_oactive—changes-in_the-._M_edicare __ Physician Fee Schedule and/or changes mandated by legislation. If you dispute this determination, please follow the appropriate appeals process listed below. Please be aware that you may appeal all of the claims from this overpayment demand letter or any part of the claims. (Applicable authorities: Section 1870(b)(c) of Social Security Act; subsection 405.350 - 405.359 of Title 42, subsection 404:506 - 404.509, 404.510a and 404.512 of Title 20 of the United States Code of Federal Regulations.) Rebuttal Process: WPS Government Health Administrators P.O.Box 1787,Madison,WI 53701 www.wpsgha.com 58-2 Page 3 Date : 03/13/2018 Letter Number : 23265667 WPS Government Health Administrators Payment Recovery P.O. Box 8064 Madison, WI 53708-8064 if you are unable to refund the entire amount at this time, advise this office immediately, with a request for an Extended Repayment Schedule (ERSI so that we may determine if you are eligible for one. Any repayment plan. (where one is approved) would run from the date of the ERS review approval date. You can visit our website at www.wpsgha.com for the ERS Request instructions. You may-elect-to haveyour overpayment(s) repaid-through the-Immediate-Recoupment process and avoid paying by check or waiting for the standard recoupment process that begins on day 41 from date of the initial demand letter. The request for immediate recoupment should be received in writing at least 16 days from the date of the initial demand letter to avoid the debt is collected in full before day 31. When the request is received after day 16 the debt shall be placed in an immediate recoupment status. If the debt is not collected in full before day 31, interest will continue to accrue until the debt is'collected in full. You must specify whether you are submitting: 1. A one-time request on the current demanded overpayment on (all accounts receivables within this demand letter) and all future overpayments; or 2. A request on this current demanded overpayment (all accounts receivables) addressed in this demand letter only. This process is voluntary and for your convenience. You can visit our website at www.wpsgha.com for the Immediate Recoupment Request instructions. You may contact this office for information on how to fax your request. If you wish to appeal this decision: If you disagree with this overpayment decision, you may file an appeal. An appeal is a review Performed by people independent of those who have reviewed your claims. The first level of appeal is called a redetermination. You must file your request for a redetermination 120 days from the date of this letter. Unless you show us otherwise, we assume you received this letter within 5 days of the date of this letter. Please send your request for redetermination to: 58-3 Page 5 Date : 03/13/2018 Letter Number : 23265667 If the facility ownership is either a sole proprietorship or partnership, your individual salary(s) may be offset if you are, or become, a federal employee. If you have filed a bankruptcy petition: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding, Medicare financial obligations will be resolved in accordance with the applicable bankruptcy process. Accordingly, we request that you immediately notify us about this bankruptcy so that we may coordinate with both the Centers for Medicare & Medicaid Services and the Department of Justice to assure that we handle your situation properly. If possible, when notifying us about the bankruptcy, please include the name the bankruptcy is filed under and the district where the-bankruptcy-isfiled. -- - -- — - --_ — — Should you have any questions, please contact your overpayment consultant at the following: Provider - Part B: 866-234-7331 We look forward to hearing from you shortly. Sincerely, Medicare Part B Recovery Unit WPS Government Health Administrators Enclosures How This Overpayment Was Determined Letter Number: 23265667 Invoice Number: 221318067900080 Claim No. Beneficiary, Name Patient No: Service Service Amount Paid Date Provider No. Date From. Date To Overpaid 221918024077120 BRIAN M IMMEL 2017-00005924-3 10/18/2017 10/18/2017 $283.35 02/07/2018 1154325579 Reason for Overpayment: The claim was incorrectly prepared causing a duplicate payment to be made to.you. Y� CI7 - EL JAMES BRAINARD, MAYOR March 26, 2018 WPS GOVERNMENT HEALTH ADMINISTRATORS PAYMENT RECOVERY P.O. BOX 8064 MADISON, WI 53708-8064 RE : Marion G Diehl 2018-00000144 :1 $337.37 Dear Sir/Madam: Enclosed you will find a check in the amount of$337.37. Medicare claim paid on 01/30/2018 incorrect modifier entered on this claim. Corrected claim sent Medicare reissued payment 03/16/2018 Duplicate payment received-created an overpayment of$337.37 Refund Health Insurance WPS Medicare. If you have any questions, please feel free to contact me at(317) 571-2604. Sincerely, Michelle T. Harrington Billing Administrator CARMEL. FIRE DEPARTMENT STEVEN A. Coals HEADQUARTERS T\VO CIvIC SQUARE, CARMEL, IN 46032 OFFICE 317.571•26OO, FAx 317.571.2615 76- 1 MEDICARE Part B CENTERS FOR MEDICARE:fir N6ECJiOMD SERVICES Letter Number: 23206777 Date: 02/26/2018 CITY OF CARMEL RECEIVED MAR 0 2 2010 2 CIVIC SQUARE CARMEL, IN 460322584 INITIAL REQUEST -RE :-MMA-935 =Overpayment-Amount- — - -- — -- - Overpayment Amount: $337.37 Outstanding Balance:$337.37 Provider Number: 317470-1154325579 Dear Sir/Madam, This letter is to inform you that you have received a Medicare payment in error, which has resulted in an overpayment subject to section 935(f)(2) of the Medicare Modernization Act (MMA), section 1893(f)(2) of the Social Security Act, Limitation on Recoupment, in the amount $337.37. The purpose of this letter is to request that this amount be repaid to our office. The attached enclosure explains how this happened. Why you are responsible: You are responsible for following correct Medicare filing procedures and must use care when billing and accepting payment. You are responsible for repayment in this matter based upon one or both of the following criteria: 1. You billed and/or received payment for services for which you should have known you ___were- not entitled to receive payment. Therefore, you are not-without fault-and are responsible for repaying the overpayment amount. 2. You received overpayments resulting from retroactive changes in the Medicare Physician Fee Schedule and/or changes mandated by legislation. If you dispute this determination, please follow the appropriate appeals process listed below. (Applicable authorities:section 1870(b) of Social Security Act; subsection 405.350 - 405.359 of Title 42, subsection 404.506 - 404.509, 404.510a and 404.512 of Title 20 of the United States Code of Federal Regulations.) WPS Government Health Administrators P.O.Box 1787,Madison,WI 53701 www.wpsgha.com 76-2 Page 3 Date : 02/26/2018 Letter Number : 23206777 Make a payment or arrange for payments: What you should do: Please return the overpaid amount to us by 03/27/2018 and no interest will be assessed. We request that you refund this amount in full. Make the check payable to Medicare Part B and send it with a copy of this letter to: WPS Government Health Administrators Payment Recovery -- --- P.0. Box-8064 - — - - -- - — - Madison, WI 53708-8064 If you are unable to refund the entire amount at this time, advise this office immediately, with a request for an Extended Repayment Schedule (ERSI so that we may determine if you are eligible for one. Any repayment plan (where one is approved) would run from the date of the ERS review approval date. You can visit our website at www.wpsgha.com for the ERS Request instructions. You may elect to have your overpayment(s) repaid through the Immediate Recoupment process and avoid paying by check or waiting for the standard recoupment process that begins on day 41 from date of the initial demand letter. The request for immediate.recoupment should be received in writing at least 16 days from the date of the initial demand letter to avoid the assessment of interest when the debt is collected in full before day 31. When the request is received after day 16 the debt shall be placed in an immediate recoupment status. If the debt is not collected in full before day 31, interest will continue to accrue until the debt is collected in full. You must specify whether you are submitting: 3. A one-time request on the current demanded overpayment on (all accounts receivables within this demand letter) and all future overpayments; or 4. A request on this current demanded overpayment (all accounts receivables) addressed in this demand letter only. This process is voluntary and for your convenience. Your request must specifically state you understand you are waiving potential receipt of interest payment pursuant to section1893(f)(2) for the overpayments. Note: Such interest may be payable for certain overpayments reversed at the Administrative Law Judge (ALJ) level or subsequent levels of appeal. You can visit our website at www.wpsgha.com for the Immediate Recoupment Request 76-3 Page 5 Date : 02/26/2018 Letter Number : 23206777 Following a decision or dismissal by the QIC, if the debt has not been paid in full, we will begin or resume recoupment whether or not you appeal to the next level, Administrative Law Judge (ALJ). NOTE: Even when recoupment is stopped, interest continues to accrue. Medicaid Offset: If this matter is not resolved, CMS may instruct the Medicaid State Agency to withhold the Federal share of any Medicaid payments that may be due you or related facilities until the full amount owed Medicare is recouped; Title 42 CFR, section 447.30(g). These recoveries will be in addition to any recoupments from other Medicare funds due you until the full amount owed to Medicare is recovered. Right to Inspect Records Prior to Referral to Treasury, In the event an Intent to Refer (ITR) letter is sent, you have the right to inspect and copy all records pertaining to your debt. In order to present evidence or review the CMS records, you must submit a written request to the address below. Your request must be received within 60 calendar days from the ITR letter date. In response to a timely request for access to CMS' records, you will be notified of the location and time when you can inspect and copy records related to this debt. Interest will continue to accrue during any review period. Therefore, while review is pending, you will be liable for interest and related late payment charges on amounts not paid by the due date identified above. For Individual Debtors Filing a Joint Federal Income Tax Return: The Treasury Offset Program automatically refers debts to the Internal Revenue Service (IRS) for Offset. Your Federal income tax refund is subject to offset under this program. If you file a joint income tax return, you should contact the IRS before filing your tax return to determine the steps to be taken to protect the share of the refund, which may be payable to the non-debtor spouse. — - -For-Debtors-that=Share a Tax ldenfification Number(§: Section 1866(j)(6) of the Social Security Act authorizes the Secretary of Health and Human Services (the Secretary) to make any necessary adjustments to the payments of an applicable provider or supplier who shares a TIN with an obligated provider or supplier, one that has an outstanding Medicare overpayment. The Secretary is authorized to adjust the payments of such a provider or supplier regardless of whether it has been assigned a different billing number or National Provider Identification Number (NPI) from that of the provider or supplier with the outstanding Medicare overpayment. Federal Salary Offset: If the facility ownership is either a sole proprietorship or partnership, your individual salary(s) Lette, umber: 23206777 Invoice Number: 224818045701800 f Claim No. Beneficiary Name Patient-No. - Service - Service - Amount- Paid-Date Provider No. Date From Date To Overpaid 221 81 801 6768790 MARION G DIEHL 2018-00000144-1 01/05/2018 01/05/2018 $337.37 01/30/2018 1154325579 Reason for Overpayment: Based on Medicare Policy, services within a Skilled Nursing Facility period are subject to consolidated billing and should not be paid separately. Our records indicate that this claim is subject to Skilled Nursing Facility consolidated billing. Therefore, payment was made to you in error. i 1 i i I i { l