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HomeMy WebLinkAbout185773 05/26/2010 CITY OF CARMEL, INDIANA VENDOR: 364208 Page 1 of 1 ONE CIVIC SQUARE ROBERT HELD CARMEL, INDIANA 46032 2065 FAHEY DR CHECK AMOUNT: $370.85 INDIANAPOLIS IN 46280 CHECK NUMBER: 185773 CHECK DATE: 5/26/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 370.85 AMBULANCE REFUND Electronic Remitance Information Print Date: 04106110 (EOB) Explanation Of Benefits (EOB) Payer Id: 00630 Production Date: 03/12/10 Receiver Id No: Z6CX Payer Information: NATIONAL GOVERNMENT SERVICES Payer Natl Id: Payer Id: 1351840597 PO BOX 6160 INDIANAPOLIS IN 462066160 Payer Contact Info: NATIONAL GOVERNMENT SERVICES INC, (866)250 -5665 TE Receiver Info: CARMEL FIRE DEPARTMENT Payee id: 1154325579 2 CARMEL CIVIC SQ CARMEL IN 460327543 Payment Info: Check EFT Trace No: 123733429 Total Payment Amount: $8,849.89 Check Issue Date: 03/12/10 Payment Method: Check Pt No Patient Name Service Date Procedure Code Line Charge Allowed Total Billed Allowed Pt. Responsible Paid HELD ROBERT C 12/30/09 A0429 RH 325.00 258.01 370.85 368.36 73.67 294.69 Claim Control 11100600 37960 A0425 RH 45.85 36.68 Claim Status: Processed as Primary Claim Remark Codes: MA01, Claim Adjustments: Total Adjustments Patient Responsibility Coinsurance Amount 9.17 Patient Responsibility Coinsurance Amount 64.50 Billed: 370.85 Contractual Obligations Charges exceed your contracted/ legislated fee arrangement. 2.49 Late Filing Fee: 0.00 Pt. Responsible Amt: 73.67 Paid: 294.69 W6- 01305 *02 *003622 -PO- 10116 -KO- 125 -CN 110 CFPA20- 070705 UNITEDHEALTHCARE. INSURANCE COMPANY �T GREENSBORO SERVICE CENTER plied ealthcar6 PO BOX 30557 A UnimdPsahh Group Company SALT LAKE CITY, UT 84130 -0557 PHONE: 1 -866- 705 -9767 DATE: 04/26/10 TIN; 35- 6000972 NP I 1164325579 MAY GROUP #:0503777 GROUP UP NAME AT&T; MEDICAL PLAN NETWORK IJV1f CHECK NUMBER: U2 56411460 CHECK AMOUNT: CARMEL FIRE DEPT AMBULANCE CARMEL FIRE DEPT AMBULANCE SV PROVIDER. 2 CA RMEL SQ CA EXPLANATION RMEL I IV 46032 OF BENEFITS PATIENT DETAIL PRODUCT MEM. ID PATIENT PAT PATIENT MEMBER CONTROL DATE PROVIDER NAME REL ACCOUNT NAME NUMBER RECEIVED OF SERVICE CHOYC* ROBERT HELD SP M ROSALIE HELD 02486590730 01 04112110 I CARMEL FIRE DEPT AA1BU SERVICE DETAIL PATIENT DATES -OF DESCRIPTION_ AMOUNT NOT PROV ADuF AMOUNT DEDUCT/ PLAN PAID TO RMJ( PATIENT NAME SERVICE OF SERVICE CHARGED COVERED DISCOUNT ALLOWED COPAY COV PROVIDER. CD' RESP, ROBERT 12/30/09 AMBULANCE 325.00 2.49 2.49 368.36 100% 73_.67 4C HELD 12/30/09 AMBULANCE 45.85 .00 4C S U B TOTAL 370.85 2.49 2.49 368.36 73:67# TOTAL PAID TO PROVIDER $73.67 REMARKS (4C) THIS PLAN DETERMINES BENEFITS ONCE MEDICARE MAKES PAYMENT. IF MEDICARE PAYS LESS THAN THIS PLAN'S BENEFIT, THIS PLAN WILL CONSIDER THE DIFFERENCE. THIS PLAN'S ALLOWABLE BENEFITS ARE BASED ON THE MEDICARE APPROVED AMOUNT IF THE PHYSICIAN OR PROVIDER ACCEPTED MEDICARE'S ASSIGNMENT OR ON THE LIMITING CHARGE IF THEY DID NOT ACCEPT THE ASSIGNMENT. THE PATIENT IS RESPONSIBLE FOR THE DIFFERENCE BETWEEN THE ALLOWABLE AMOUNT AND THE TOTAL AMOUNT PAID BY BOTH PLANS. THE PATIENT MUST PAY ANY APPLICABLE PLAN DEDUCTIBLES AND COPAYS BEFORE THIS PLAN CAN PAY ANY BENEFITS. UNITEDHEALTHCARE IS IMPROVING SERVICE TO YOU BY ADOPTING ELECTRONIC PAYMENTS STATEMENTS.(EPS) AS A STANDARD WAY TO PAY CLAIMS. EPS WILL DRAMATICALLY REDUCE THE TIME AND EFFORT YOUR ORGANIZATION SPENDS ON ADMINISTERING PAPER CHECKS AND EXPLANATION OF BENEFITS. GET A HEAD START AND ENROLL TODAY BY SELECTING THE ELECTRONIC PAYMENTS STATEMENTS LINK FOUND ON THE HOME PAGE OF WWW.UNITEDHEALTHCAREONLINE.COM OR CONTACT US AT 1- 866 -UHC -FAST (1- 866 -842- 3278); OPTION S. FOR MORE INFORMATION ABOUT OUR FREE OR LOW COST SOLUTIONS FOR SUBMITTING CLAIMS ELECTRONICALLY TO UNITEDHEALTHCARE AND OTHER PAYERS, PLEASE CONTACT US TOLL FREE AT 1- 800- 842 -1109, OPTION 3. PAYMENT OF BENEFITS HAS BEEN MADE IN ACCORDANCE WITH THE TERMS OF THE MANAGED CARE SYSTEM. THIS PAYMENT HAS BEEN ADJUSTED BASED ON THE AMOUNTS PAID BY MEDICARE AND /OR OTHER INSURANCE. Detach Check Detach Check 50 837 JPMorgal� Chase Bank, NA: 213 UNITEDHEALTHCARE INSURANCE COMPANY Syracuse, NY SERVICE CENTER GREENSBORO �y .PO BOX, 30557 ;SALT LAKE. CITY; UT 84136 0557 ,`i DATE ``04/26/ 1 Q _PHONE.,..1.866- 7.059767 W6- 01305.003622= PO`f01.16 =K0 125 CH: 110 PLEASE PRESENT PROMPTLY. ?FOR RAYMENT, CONTRACT': 503777' PAY *SEVEW- Y:THRE€ &:::67/100 DOLLARS. PAY CARMEL 'FIRE ''DEPT 'AMBULANCE MBULANCE vc T TO THE. CARMEL FIRE DEPT AMBULANCE SV 2 CIVIC SQ- ORDER OF',- CARMEL 'I :N 46032 AGTkiORIZ£D.3lGNATUR° filvilmnulllliirllill €�lunllu iil i i 1 II h VIII Ir dII11111iliIllnldEulllllliidnllndul of I iIEIIIIIIhIIIIEIIiIlllllllllillllllllilllllllllllllllllktlllllllllllflll1111IIlIIIIIIIIIIIIIIIIiIIIIIIIIIIfII11IIlIfIIIIIIIIiIIIfINIIIiIIIIIIIIIIBIIIIIIIIIIIIIIIIIIIlIII411IirIIIIIIIIIIIIIIIIIIkII] IIIIIIIIIIIIIIlI111I111I1iI11IIIIl1IIIIII11Il1IIlIIIIIIIIIIiIIIIIIfIIIIIIIIIfIIII II° 8 b l Lis Q!I I..Q 2 11 9 17 91. I L 0 &96 D 4 II° .M. Payable To: CARMEL FIRE DEPARTMENT ROBERT C HELD Run Date RECEIVED MAR 12/3C)/2009 Amount Paid APPROVED BY THE S'rATE BOARD OF ACCOUNTS FOR CITY pF CARMEL, 1999 ROBERT C. HELD L -149 67 M. ROSALIE MELD 70000©067112 2065 FAHEY DA. Iw INDIANAPOLIS. IN 46230 DATE W PAY TO THE'��/ W ORDER OF DOLLARS 8 /7 /l �y MEMO M' itq Date: 05/11/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederallD# 356000972 U f ACS UN FC)M ,vim Bill To: ROBERT C HELD ICD -9: 7295 71945 72885 E8888 2065 FAHEY DR INDIANAPOLIS, IN 46280- From: 2065 FAHEY DR To: ST. VINCENTS HOSPITAL 1 MEDICARE PART B Patient: ROBERT C HELD 2065 FAHEY DR Insurance INDIANAPOLIS, IN 46280 2 UNITED HEALTHCARE/ 30557 Patient No: 815792042 WE CANNOT BILL MEDICARE WITHOUT AN AUTHORIZED SIGNATURE ON FILE. PLEASE SIGN IN SECTION 1 OR 2 AND RETURN IN THE ENCLOSED ENVELOPE PROMPTLY. THANK YOU. Total Amount Total Paid Balance $370.85 $370.85 $0.00 CPT Date Description Charges Credits 12/30/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 12/30/2009 MILEAGE A0425 $45.85 03/03/2010 PAYMENT $370.85- 03/17/2010 MEDICARE PAYMENT $294.69 03/17/2010 ASSIGNMENT MEDICARE $2.49 05/03/2010 COMMERCIAL INSURANCE PAYMENT $73.67 05/11/2010 REFUND 370.85 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 05/11/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal iD# 356000972 Bill To: ROBERT C FIELD ICD -9: 7295 71945 72885 E8888 2065 FAHEY DR INDIANAPOLIS, IN 46280 From: 2065 FAHEY DR To: ST. VINCENTS HOSPITAL 1 MEDICARE PART B Patient: ROBERT C FIELD 2065 FAHEY DR Insurance INDIANAPOLIS, IN 46280- 2 UNITED HEALTHCARE/ 30557 Patient No: 815792042 WE CANNOT BILL MEDICARE WITHOUT AN AUTHORIZED SIGNATURE ON FILE. PLEASE SIGN IN SECTION 1 OR 2 AND RETURN IN THE ENCLOSED ENVELOPE PROMPTLY. THANK YOU. Total Amount Total Paid Balance $370.85 $741.70 370.85 CPT Date Description Chartles Credits 12/30/2009 BASIC LIFE SUPP-EMERGENCY A0429 $325.00 12/30/2009 MILEAGE A0425 $45.85 03/03/2010 PAYMENT $370.85 03/17/2010 MEDICARE PAYMENT $294.69 03/17/2010 ASSIGNMENT MEDICARE S2.49 05/03/2010 COMMERCIAL INSURANCE PAYMENT $73.67 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995) CITY OF CARMEL 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. Payee ALP �Jl Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) l Total 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 Clerk- Treasurer VOUCHER NO. WARRANT NO. ALLOWED 20 IN SUM OF 70- ew V 7C. ON ACCOUNT OF APPROPRIATION FOR �n 6�clQU� /loo 2 &1v Board Members Po# or INVOICE NO. ACCT #/TITLE AMOUNT DEPT_ 1 hereby certify that the attached invoice(s), or 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 MAY 242010 r 2 Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund