HomeMy WebLinkAbout326742 06/29/18 *. CITY OF CARMEL, INDIANA VENDOR: 372462
i®
ONE CIVIC SQUARE FLORIDA BLUE CHECKAMOUNT: $********79.43*
s9 �: CARMEL, INDIANA 46032 P.O.BOX 121213 CHECK NUMBER: 326742
DEPT 1213 CHECK DATE: 06/29/18
DALLAS TX 7 531 2-1 21 3
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 79.43 OTHER EXPENSES
VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201 (Rev.1995)
Vendor# 372462 ALLOWED 20 ACCOUNTS PAYABLE VOUCHER
FLORIDA BLUE IN SUM OF$ CITY OF CARMEL
P.O. BOX 121213 An invoice or bill to be properly itemized must show:kind of service,where performed,dates service
DEPT 1213 rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc.
DALLAS, TX 75312-1213
Payee
$79.43
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 $79.43 1 hereby certify that the attached invoice(s),or 6/19/18 0 $79.43
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,June 20,2018
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
20Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer
Y
` � E
I
CIT #° SEL
JArtims BRA iARD, MAYOR
May 29, 2018
FLORIDA BLUE
DEPT 1213
PO BOX 121213
DALLAS, TX 75312-1213
RE : OVERPAYMENT RUN # 2017-00005907:1 CLINTON BROOKE
Date of Service 10/17/2017
MEDICARE SUPPLEMENT OVERPAYMENT:
Overpayment Refund $79.43 enclosed for FLORIDA BLUE
05/25/2018 FLORIDA BLUE paid this claim twice- check# 310436981 $158.86.
This created an overpayment of$79.43
Refund to be sent to Blue Cross Blue Shield of Florida.
If you have any questions, please feel free to contact me at (317) 571-2604.
Sincerely,
Michelle T. Harrington
EMS Billing Manager
CAR[VIFL FIRE DEPARTMENT
STEVEN A. CouTs HEADQUARTERS
Two Clvic SQUARE, CARMEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615
Mellon
Overpayment Recovery Receipts
Dept. 1213
PO Box 121213
Dallas TX 75312-1213
CLAIM FOR OVERPAYMENT
OUT OF STATE PHYSICIAN Customer ID: OS-037815
2 CIVIC SQUARE Invoice Number: 105231936
CARMEL IN 460322584 Invoice Date: 05/22/2018
NPI Number: 1154325579
RECEIVED MAY 2 91018
Dear Sir/Madam
This letter represents a request for a refund due to Florida Blue/Health Options Inc. (HOI) as a result of an
overpayment of the following claim
Patient: Brooke,Clinton Patient ID: H71702884 Patient Account Number:2017-00005907-1
Dates of Service: 10/17/2017-10/17/2017
Invoice Number: 105231936 Audit Number:
Claim Number Patient Responsibility FB Check Date/Number
Original Invoice Amount $79.43 Original Q100000632763175 Original $0.00 05/21/2018 310436981
Corrected $0.00
Total Amount $79.43 Reason for Overpayment: Claim Paid Incorrectly
Cash Received/Netted $0.00 CHECK NEVER RECEIVED
PriorAd'ustments $0.00
Balance Due $ 79.43
Procedure Codes:
Additional Information (if applicable)
Other Carrier Name: WPS - MAC J8 IN PART B Accident Date:
Other Carrier Payment: 311.36 Case Number:
FB Allowance: 581.95 Total Combined Payment: $390.79
OTAL BALANCE DUE: $79.43
Please return a copy of this letter with your check made payable to Florida Blue to the address listed below. In
the event thatyyou already refunded the overpayment or deny/contest the overpayment claim, please advise us in
writing within 40 days and include a copy of this communication.
In accordance with Florida Statutes 627.6131 and 641.3155, ou have 40 days from receipt of this letter to notify
FB in writing if you denyy or contest the findings. Per Florida Statute you must provide specific and detailed
information regarding the claim or any portion of the claim that is in dispute. If no written response is received
within the 40-day time limit, we may proceed with recovery by offsetting the overpaid amount against future claims
payment or we may place the recovery with a Third Party Collections Vendor.
Mellon
Overpayment Recovery Receipts
Dept. 1213
PO Box 121213
Dallas TX 75312-1213
Thank you for your cooperation and prompt attention to this matter.
B1ueCross B1ueShield
%i of Florida
® ® m-
Anl�bWd.MLk-fft PO Box 44267
EU-G- °EM-ShIMA B0d'U 532 Riverside Avenue
05/21/2018 Jacksonville,FL 32231-4267
Page 3
AHINh! RI.E.......R ME ::> :;:>::>:,,<;:: <::>:.:>:«:::»::>:>:»::: a ID 00972:i:>?i:>i::'»::`:::::<:;<:::»`i:"::'r?}>::»':............>::::>':»[:::>:
_. .... ...............T..x.....3.54.U........ ........................:...........................................ChecklSF'f.:Nutriber..3'f.�A3698�......................:Tot Rafd ........ ....................
Services Delivered Patient Name Member Number SCCF Medicare Report Number HIC Number MPD Amount
- - .. --- -------- - - --- ----- ...------.._._.. -- ------ -- --- ----- --- . -._.. ----- _...----.----
by Patient SOS _.._...-_-- -.---._.._-- .._..- -Remarks
Claim No. D.R.G. Account Claim From Claim To CPT/Rev Code HCPC Days/ Allowed Diff Other Patient Amount Interest
Adjustment ID/S.R.G. Number Date Date M1 M2 Code Units Charges AmountApplied Carrier Co Pay Cc Ins. Deductible Resp. Paid Payment
A0000 CLINTON D BROOKE XJMH71702884 $0.00
Q100000632763175 2017-00005907-1 10/17/2017 10/17/2017 AO429 RH 0001 $489.25 $489.25 $420.76 $0.00 $0.00 $0.00 $0.00 $68.49
Q100000632763175 2017-00005907-1 10/17/2017 10/17/2017 AO425 RH 0008 $92.70 $92.70 $81.76 $0.00 $0.00 $0.00 $0.00 $10.94
TOTAL: $581.95 $502.52 $0.00 $0.00 $0.00
$581.95 $0.00 $0.00 $79.43
A0000 CLINTON D BROOKE XJMH71702884 $0.00
C0001 R1019458533 2017-00005907-1 10/17/2017 10/17/2017 A0429 RH 0001 $489.25 $489.25 $420.76 $0.00 $0.00 $0.00 $0.00 $68.49 1,2
C0001 R1019458533 2017-00005907-1 10/17/2017 10/17/2017A0426 RH 0008 $92.70 $92.70 $81.76 $0.00 $0.00 $0.00 $0.00 $10.94 1,2
Remarks/Reasons: (1)OCPMT(2)PCNTR
TOTAL: $581.95 $502.52 $0.00 $0.00 $0.00
$581.95 $0.00 $0.00 $79.43
D ition .L:.
Remark Reason Defin
1 OCPMT Claim adjusted because charges have been paid by another payer.
2 PCN TR Allowed amount based on agreement.
For questions regarding this Remittance Advice,call 1-877-352-2583 or write to us at the address listed on the top of the Remittance Advice.
PYOP0001-RA-18141-31627