HomeMy WebLinkAbout324885 05/09/18 CITY OF CARMEL, INDIANA VENDOR: 371761'ONE CIVIC SQUARE UNITED OF OMAHA LIFE INSURANCE CGHECK AMOUNT: $
......**76.18
ao CARMEL, INDIANA 46032 8 MEDICARE SUPPLEMENT CLAIMS DEPT CHECK NUMBER: 324885
OMAHA NE 68175 CHECK DATE: 05/09/18
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
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JAN Es BRAINARD, MAYOR
May 4, 2018
United of Omaha Life Insurance Company
8 Medicare Supplement Claims Department
Mutual of Omaha Plaza
Omaha, NE 68175
RE : OVERPAYMENT RUN#2018-00000721:1 ELOISE MCQUINN
Date of Service 02/04/2018
MEDICARE SUPPLEMENT OVERPAYMENT:
Overpayment Refund $76.18 enclosed for United of Omaha Life Insurance Company.
03/01/2018 United of Omaha paid patient's copay$152.01.
04/26/2018 Medicare reprocessed this claim and patient's new copay amount due $75.83.
This created an overpayment of$76.18.
Refund to be sent to United of Omaha Life Insurance Company.
If you have any questions, please feel free to contact me at (317) 571-2604.
Sincerely,
Michelle T. Harrington
EMS Billing Administrator
CA&YIEL FIRE DEPARTMENT
STEVEN A. CouTs HF-kDQuARTERs
Two CIVIC SQUARE, CAMMEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615
UNITED Of OMAHA LIFE INSURANCE COMPANY
3300 Mutual of Omaha Plaza
Omaha,NE 68175
MMM-5/01naHa mutualofomaha.com
April 28, 2018
RECEIVED MAY 0 3 2018
CITY OF CARMEL FIRE DEP
2 CIVIC SQ
CARMEL IN 46032-2584
Claim Number: 584585767000
Policy Number: 942793-88
Patient: MCQUINN/ELOISE/P
Date of Birth: 11/28/1945
Patient Account: 2018-00000
Date of Service From: 02-04-18
Date of Service To: 02-04-18
Our Draft Number: 87758303
Refund Amount Due: $76.18
Audit Number: 009
Attention: Patient Accounts
Based on information we received the benefits were incorrectly considered resulting in the above
date(s) of service being overpaid.
This information was based on the Medicare's adjusted Remittance Advice (MRA). Please refer
to this MRA to determine correct claim liability.
At this time we are requesting a refund of$76.18. Please make your check payable to United of
Omaha Life Insurance Company and mail your check to the following address:
United of Omaha Life Insurance Company
8 Medicare Supplement Claims Department
Mutual of Omaha Plaza
Omaha NE 68175
We are unable to apply this overpayment from any future benefits due.
ECSM-P180428043006000033
020200000000000000