188459 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