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Home My WebLink About188459 08/03/2010 F CITY OF CARMEL, INDIANA VENDOR: 364489 Page 1 of 1 4i ONE CIVIC SQUARE PALMETTO GBA RAILROAD MEDICARE CHECK AMOUNT: $252.95 CARMEL, INDIANA 46032 PO BOX 10066 AUGUSTA GA 30999 CHECK NUMBER: 188459 CHECK DATE: 8/3/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 252.95 AMBUL REFUND We are Plossadlo offer Online Provider Services (OPS),.our free Internet based, Provider self-service portal: :,This 'application- provides access to li?ibility,,claims'status, remittances online and financial information. For a informat ion, us at www.Palmst4oGBA.com/rr. Provider Contact Center hours 13:30 a.m. t o .'4:30 p.m. EST for all time zones excePt.PST which:roceivas service f r om: 8 1 0 a. t o: 4: 0 0 P. In. PST: CSR.only..(aes) 3.55-916S i IVR only (877) 288 Telephone Reopening (866) 324-3073 Provider Enrollment Support (866) 899-5227 PERF PROV SERV DATE Lql :NO MODS PROC�"... ALLOWED DE%& COINS GRP/RC PROV PD NAME NANGLE, MARY HIC MA71012 1 01001577 ASG Y MOA Wfr 0611 061110 4L 2. 0 A0429 RH 650:00 632.38 0.00 126.48 CO-45 17.62 505190 0611 061110 41 3.0 A0425 RH 19:6.5 19.65 0 3.93 15.72 PT RESP 130.41 CLAIM 669.65 652.03 0100 130.41 17.62 521.62 CLAIM INFORMATION FORWARDED10: UNITEDHEALTH GROUP NET 521.62 TOTALS: OF BILLED ALLOWED DEDUCT COINS TOTAL PROV PD PROV CHECK CLAIMS AMT AMT AMT ANT RC-AMT AMT ADJ AMT AMT 1 669.65 6S2.03 0 130.41 17.62 521.62 0.00 521.62 GLOSSARY: Group, R:a;on, MOA, Remark and Adjustment Codps CO C ractual Obligation. Amount for which the provider is financially liable. The patient may not be billed for this amount. 45 Charges exceed Your contracted/legislated fee errang Imant. This change to he effective 61IY07: Charge exceeds fee schedule/maximum allowable or con fee arrangement. (Use, Group Codes PR or CO depe nding upon liability). MA01 Alart: If you do not agree with what we approved for these services, You may appeal our decision. To make aura that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal. However, in order to b eligible for an appeal, You must write to us within 120 days of the date You received this notice, unless you have good reason for being late. MA19 A a The claim information is also b:ing forwarded to the Patient's supplemental insurer. Send any questions regarding supplementa anafits to them. g bt u J7, "M ','4 'CH 1 1— uj-�5,i��"" 21"T 4 j',EXT� HECK x724 i, -U, E C �R P a I T�!'C C C- K-, N j�M org a n'wCh 6 se��B ank L 'l wl�A,:��,�:,i%��,1,1�,��,,�?�S",�*". ,S P 0 V I D E R N 0: SI-i "'D earborn ;A� M 9, 4 'CENTS -,Uuul `J%2, 6 ii� G 01 1 C mo DAY �YEAR' PAY�DOLLARS AY TO THE ORDER OF C 07 1161 10 *******521162 C CARMEL FIRE DEPT AMBULA VOID IF NOT CASHED WITHIN ONE YEAR 2 CIVIC SQUARE CARMEL, IN 46032-2584 *******521DOLLARS AND 62CNTS 499041 005494 v 2 1, L S 2 3511' 410 7 2 1 2 9 2 7 000378 Date: 07/28/2010 CARMEL FIRE DEPARTMENT EMERGENCY VIED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal 1D# 356000972 H Bill To: MARY M NANGLE ICD -9: 036.9 4787 ALDERSGATE DR CARMEL, IN 46032 From: 4787 ALDERSGATE DR To: ST. VINCENTS HOSPITAL CARMEL 1 UNITED HEALTHCAREIRR Patient: MARY M NANGLE MA710120343 4787 ALDERSGATE DR Insurance CARMEL, IN 46032 2 HARP /UNITED HEALTHCARE Patient No: 201001577 1889764411 WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW, THANK YOU. Total Amount Total Paid Balance $344.65 $521.62 176.97 CPT Date Description Charges Credits 06/11/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 06/11/2010 MILEAGE A0425 $19.65 07/27/2010 MEDICARE PAYMENT $521.62 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 0712812010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317 )571 -2605 FederalID# 356000972 C KI'e� HISTC4 Bill To: MARY M NANGLE ICD -9: 036.9 4787 ALDERSGATE DR CARMEL, IN 46032 From: 4787 ALDERSGATE DR To: ST. VINCENTS HOSPITAL CARMEL t UNITED HEALTHCARE /RR Patient: MARY M NANGLE MA710120343 4787 ALDERSGATE DR Insurance CARMEL, IN 46032 2 HARP /UNITED HEALTHCARE Patient No: 201001577 1889764411 WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU. Total Amount Total Paid Balance $344.65 $277.48 $67.17 CPT Date Description Charges Credits 06/11/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 06/11/2010 MILEAGE A0425 $19.65 07/27/2010 MEDICARE PAYMENT $521.62 07/28/2010 REFUND 252.95 07/28/2010 ASSIGNMENT MEDICARE $8.81 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Prescribed by state Board of Accounts City Form No. 201 (Rev. 1995) ACCOUNTS PAYABLE VOUCHER 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 Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) M aru AM Total L 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. f 20 Clerk- Treasurer VOUCHER NO. WARRANT NO" s ALLOWED 24 IN SUM OF �J ,/�ccnc�s a 914 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 AUG c Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund