187749 07/21/2010 CITY OF CARMEL, INDIANA VENDOR: T0002820 Page 1 of 1
�o ONE CIVIC SQUARE CIGNA HEALTHCARE INC
I CARMEL, INDIANA 46032 PO BOX 182223 CHECK AMOUNT: $68.43
CHATTANOOGATN 37422 CHECK NUMBER: 187749
CHECK DATE: 7121/2410
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 REFUND 68.43 REFUND
Date: 07114/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal 1D# 356000972
4.4 OUNT HIS R
Bill To: ROSALIE MIKESELL ICD -9: 71945 7295 E9671
818 S GRANT AVE
CRAWFORDSVILLE, IN 47933
From: 10401 N MICHIGAN RD
To: ST. VINCENTS HOSPITAL
1 MEDICARE PART B
Patient: ROSALIE MIKESELL 310361061A
818 S GRANT AVE Insurance
CRAWFORDSVILLE, IN 47933- 2 CIGNA 15200
Patient No: 200902961
UO323094702
PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE
ENCLOSED SELF ADDRESSED STAMPED ENVELOPE, THANK YOU.
Total Amount Total Paid Balance
$344.65 $689.30 344.65
CPT
Date Description Charges Credits
10/19/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
10/19/2009 MILEAGE A0425 $19.65
03/17/2010 MEDICARE PAYMENT $273.73
03/17/2010 ASSIGNMENT MEDICARE $2.49
03/30/2010 COMMERCIAL INSURANCE PAYMENT $68.43
06/22/2010 COMMERCIAL INSURANCE PAYMENT $344.65
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 07/14/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal m# 356000972
OUNT
Bili To: ROSALIE MIKESELL ICD -9: 71945 7295 E9671
818 S GRANT AVE
CRAWFORDSVILLE, IN 47933
Fram: 10401 N MICHIGAN RD
To: ST. VINCENTS HOSPITAL
1 MEDICARE PART B
Patient: ROSALIE MIKESELL 310361061A
818 S GRANT AVE Insurance
CRAWFORDSVILLE, IN 47933- 2 CIGNA 15200
Patient No: 200902961 UO323094702
PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE
ENCLOSED SELF ADDRESSED STAMPED ENVELOPE, THANK YOU.
Total Amount Total Paid Balance
$344.65 $620.87 276.22
CPT
Date Description Charges Credits
10/19/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
10/19/2009 MILEAGE A0425 $19.65
03/17/2010 MEDICARE PAYMENT $273.73
03/17/2010 ASSIGNMENT MEDICARE $2.49
03/30/2010 COMMERCIAL INSURANCE PAYMENT $68.43
06/22/2010 COMMERCIAL INSURANCE PAYMENT $344.65
07/14/2010 REFUND -68.43
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
L
C ;t 7 NNEC'I' ICU' I' Gf: NI: RAt•I.IPI:INSURANC:I;C,ON1I'ANY
BOURBONNAiSCLAIM OFFICE
f'. f.), B0X 1132223
Cl IA'1'I•AN00(iA TN 37422 -722:1
coNNla: rlr. u rcl NEltAl.1.111 INSURANCE COMPANY CIGNA HealthCare
AS AGENT FOR
RR DC)NNL:I.LEY fz SONS Provider Numtrer:
�o
356000972 0000
Wte through which claims wereprocessed:
03/23/2010
ItIitLII, iIL„ 1111itIl, IIIIsIal11111 4Inlir111 let 111111It111 Payloc
CARMEL FIRE DEPT 465
2 CARMEL CIVIC SQ
CARMEL IN 46032 -2584 How to Contact Us
RIECE MAR 3 O 7 Q I� Mail to the return riddress iu replier
left corner of this page
I•honc: (800) 656 -1691
Provider.Explanaation otMeaiiccld ptiprielat
Unclerstandirig this Benefits Statement
Th is page provides a swrinlary of the paynlen is made this period.
The accompanying pages give more detail on the claims we processed for this period. Please review built the front and back of each page to see prow ltrc
benefit amounts in the Provider Explanation of Nlcclical I'aynient Report were determined.
iri the event a Clain is denied......
Rights o f Review and Appeal For Physician or Healtli Care Provider
If you iMVC dtucSlinrlS or disagree with the 1myrilet5t ideni ifictl un thii I :xplanation of tv4edical I'aymerit Report you may ask to have it reviewed.
tf you have a contracttial agreement with CK.NA HcalthC:are, plcttse refer Lo Lhe procedural guidelines associated with your Ctr.,NA t3ealllrCale
c'ontnacl, tic call otir oflice for assisluncc.
Rights of Revietv and Appeal For Employee
Call MctnberSet at the toll Ike number un this Explanation of IlenefitS (B)R) or your 11) Card if you have questions regarding
this 1`013.
It you'rC not satisfied with th coves �y decision, you can start the Appeal process; by sul)mittiq a written request to the address
listed in your plan materials within 7 8t) hays of receipt of' this I:OR (11111ess a longer time is pernritied by our plan),
Send a copy ()F thiti E013 alt-rig with any relevant addl ti !nat informal ion (C. g. belletit clocurnents, clinical records) which helps to
de:monstratc that your clailu is covered under the plan. Contact Member SeYOCCS it you need further instnictions on how and
where to send your reclucst for review.
lie sure to include your 'Q Name, 2) Operation [.o cation /Group Nuniher, :3) IiniploycC /Patient ID number, 4) Name of le patient
and relationship[, and S) Attention: Appeals Unit un all supportin r documents,
You are elititledl to receive free upon reclucst aCC:ess tds, and Copies o�, all documents, records and other information relevant to
vuur claim for bcnefits.
j uu will be notified oft he final decision in a fit ely man ner, as descrihed in ppour plan nutierials. If yore plan is governed! by
EltltiA you also have the right to hying legal action under section 502(a) of GR15A toflowing our review.
Pay tient Summary
CheckNurnber, 00 l Checft Anaaart:
$68. C'l�zc[.1)mtte: 03/
28 9( aF20LLAIM Medical Prmider EOP
V
Detach on Perforation a Cash Promptly
ton Belaw Pteas
X CO]SNkC I I(U C t istV1 ItAI LEk I IN3UltAN(L (,UhfP�YNY CFiECt( t!
1 ;Aa ttic, t NT Ic)lt
Itll'Q�iNNti I Si JUNJ 5
'fit 20%
GNA DATE Prgvtder .3
c
FayLpc 465' iO3423 20 i 0 356000972 OOOfi
SIXTY EIGHT DO LLARS AND 43 CENTS
f
Pty CARt1EL'FIRE °1]EP7
1�oElars *)EXX 68 43
to the 2 CRRttfL CIVIC 5th;
CAf2MEL "IN 46032 2 584 f
Vord K tVot Cashed Wftlitn 113ti pays
of
NC1v cA511.It, Wl l:nw;Rh
n
THE IGINAL UMENT HAS A REFLECI WATERMARK
G2434CQ6 28'2008 PROCLAIM Medical Prondei EbP ON HE
t3ACiC TIV
H�LD AT APt AjIGL E:
T
p° 5 6 20 396 2 li° 1:0 3 4 LOD 2091: 1,0008"a13
Provider Expianation OfMedical PaymeritReport
ProviderNumber Provider Name Date through which claims were on
356000972 0000 I CARMEL FIRE DEPT
PrGCe�ure Adjusted Billed allowed`' \ot.Coveredl,\' Deduct /Ca a Coinsurance �.Adjusted 1� PRG/
c0i
me Procedure Date Procedure t Proced'ure Cod Per Nor
A mount Code Code: d
Iscou t� Amou amount; -:Arnount' yp dumber
amount f
PATIENT NAME; ROSALIE MIKESELL PATIENT#: 200902961 OPERATION LQCATION/GROUPO 25585-9-2445701 RE
MEMBER RAKE: BILLY J MIKESELL rAJBSr-RIBER# UO323D947 REF#: 4651007699254
1 10192009 A0429 325.00 322.51 2.49
2 10192009 A0425 19.65 19.65 D.00
TOTAL 344.65 j 342
THE $500 INDIVIDUAL DEDUCTIBLE HAS BEEN SATISFIED FOR 2 009
THE 52,000 INDIVIDUAL -CUT-OF-POCKET LIMIT' HAS BEEN REACHO.FOR-2009-----
WHY WAIT FOR THE HAIL?' VIEW ELIGIBILITY, BENEFITS OR CLAIM DETAILS ONLINE
ANYTIME AT HTTP:.',/WWW.C.TGNA.CCM/HEALTH/PROVI13ER/
IPAY14EHT OF 568.43 TO CARMEL FIRE DEPT
Iw AAI MAN
THE ABOVE PAYMENT AMOIJNT INCLUDES ADJUSTMENTS FOR OTHER INSURANCE COVERAGE
A) THIS PROVIDER ACCEPTS MEDICARE'S ASSIGNMENT AND AGREES
TO CHARGE ONLY THE AMOUNT APPROVED BY MEDICARE- THIS
AMOUNT WAS DISALLOWED BY MEDICARE.
;24360 03-23-2006
0 r 9 6 L C
CLAIM NO 14- 2384-506 POLICY NO 1609 180 -14J LOSS DATE 10 -19 -2009 PAYMENT NO 1 18 720533 J
Coverage Description Amount 'Pa`: Cd DATE 06 -18 -2010
MEDICAL PAYMENT $344.65 600:.::''` 2 AMOUNT $344.65
TIN 14- 356000972
ENTERED BY SIMON MONICA
"'`AUTHORIZED BY SIMON, MONICA
PHONE (866) 648 -0715
REMARKS 10/19/2009
f
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 18 720533 J
WEST LAFAYETTE, IN JPMORGAN CHASE BANK, NA 56- 1544/441
MPC INDIANA 18-501 L025 COLUMBUS, OH
06 -18 -2010
CLAIM NO 14- 2384 -506 INSURED MIKESELL, ROSALIE DATE MM DD Y Y Y Y
a
LOSS DATE 10 -19 -2009 ON BEHALF of ROSALIE MIKESELL
v,
****************EXACTLY THREE HUNDRED FORTY-FOUR AND 65 44 65
Pav to the 4 '5
Order of CARMEL FIRE DEPARTMENT
2 CIVIC SQ
CARMEL IN 46(}32 -2584 `m
APPROVED BY
RECEIVED JUN 2 2 2010
CLAIM NO 14- 2384 -506 POLICY No 1609- 180 -14J LOSS DATE 10 -19 -2009 PAYMENT No 1 18 720533 J
CoVera a Deseri t.iori kmounti
>ebL .'Pa <,Cd' DATE -18-2010
MEDICAL PAYMENT $344.65 600 2 AMOUNT 344.65
TIN 14- 356000972
L_ T/8, I F t B-) I Rt F E R k, K �m
t� i v...F t F Ham L.r" 3
AUTHORIZED BY SIMON, MONICA
PHONE (866) 648 -0715
REMARKS 10/19/2009
STATE FARM MUTUAL AUTOMOBILE INSURANCE COM
WEST LAFAYETTE !N JP,.MORGAN CHASE BANK NAr "56 1544/441
f QOLUM8U5 'OH
awsv,� "cam :MPC Id D IANA 1'8 501 0025
CLAIM No 14.2384 506 INSURED °MIKESELL ROSALIE
DAT
BOSS DATE O :fb 2009, ON BEHALF, OF, ROSALIE MIKESELL,
**EXACTLY THREE HUNDRED FORTY-FOUR AND 651100 DOLLARS' *3`44.65
Pay io the
.'Orderaf. CARMEL FIRE DEPARTMENT
2.CIV1C SQ
CARMEL IN 46032 2584 Cs N'. f
AUTHORIZED'SIGNATURE
AUTHOF
W0,SIGNATURE
o a a o-
11 °m8L77205331+° 1 :04 L,IL5L,431:62E2902331+°
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
�i1 nJ'J r2 1 pCIVXC lip Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
'L
Total �p
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
e2k Al a 60 0,, 0 J /l� 7 S
t V-3
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I 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
UUL 1 2M
r
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund