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Home My WebLink About189822 09/14/2010 CITY OF CARMEL, INDIANA VENDOR: 364692 Page 1 of 9 ONE CIVIC SQUARE HIGHMARK BLUE SHIELD CARMEL, INDIANA 46032 PO BOX 890035 CHECK AMOUNT: $275.72 o COMP HILL PA 17089 CHECK NUMBER: 189822 CHECK DATE: 9/14/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 275.72 AMBUL REFUN Date: 09/10/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal !D# 356000972 Bill To: ALBERT W KOESKE ICD -9: 9593 14208 JOSHUA DR CARMEL, IN 46033 From: 146TH LA FITNESS To: ST. VINCENTS HOSPITAL CARMEL MEDICARE PART B Patient: ALBERT W KOESKE 396340250A 14208 JOSHUA DR Insurance ANTHEM BCIBS /37010 CARMEL, IN 46033- 2 WAM 107555922001 Patient No: YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU. Total Amount Total Paid Balance $344.65 $620.37 275.72 CPT Date Description Charges Credits 07/09/2010 BASIC LIFE SUPP EMERGENCY A0429 $325.00 07/09/2010 MILEAGE A0425 $19.65 08/17/2010 BLUE SHIELD PAYMENT $275.72 09/08/2010 COMMERCIAL INSURANCE PAYMENT $344.65 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 09/10/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: ALBERT W KOESKE ICD -9: 9593 14208 JOSHUA DR CARMEL, IN 46033 From: 146TH a0 LA FITNESS To: ST. VINCENTS HOSPITAL CARMEL 1 MEDICARE PART B Patient. ALBERT W KOESKE 396340250A 14208 JOSHUA DR Insurance ANTHEM BC /BS /37010 CARMEL, IN 46033- z WAM107555922001 Patient No: YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU. Total Amount Total Paid Balance $344.65 $344.65 $0.00 CPT Date Description Ch� arges Credits 07/09/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 07/09/2010 MILEAGE A0425 $19.65 08/17/2010 BLUE SHIELD PAYMENT $275.72 09/08/2010 COMMERCIAL INSURANCE PAYMENT $344.65 09/10/2010 REFUND 275.72 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 r: BILL'? "INQUIRIES 'ONLY Ind,, 2501 WILMINGTON'RD" CHECK REFERENCE 'CHECK DATE NEW CASTLE, PA 16105 g 25853395 09/02/10 800- 245 -1700 Liberty B. CODE Mutual. ILiCA.�v CHECK AMOUNT BLOCK.NUM BER j� 251 *$344.65 004357 SEND "BILLS TO. PAGE 1.OF- PO BOX 1052 MONTGOMERYVILLE, PA 18936 -1052 OSN: VV0101090201- 004361 888- 288 -7218 CLAIM NO: 015455783 -0003 INVOICE NO: 750017712 POLICY NO: A06- 248 317112 -400 PROVIDER 102691 PAYEE: CARMEL FIRE DEPARTMENT PATIENT ACCT. BILL PROV: CARMEL FIRE DEPARTMENT DOI: 07/09/10 CARMEL FIRE DEPARTMENT PATIENT: KOESKE,ALBERT CARMEL, IN p 14208 JOSHUA OR RECEIVED SEP 2010 CARMEL, IN 46033 -8704 A USA INSURED: KOESKE,ALBERT' PROVIDER: CARMEL FIRE DEPARTMENT DATES OF SERVICE: 07/09/10 07/09/10 DATE OF PROCEDURE MOD REVIEW PPO PREV CURR EXPL SERVICE CODE CDE SERVICE DESCRIPTION UNITS CHARGES ALLOW ALLOW PAID PAID CODES 07/09/10 A0429 AMBULANCE SERVICE BLS 001 325.00 325.00 325.00 07/09/10 A0425 GROUND MILEAGE 003 19.65 19.65 19.65 TOTAL CHARGES: 344.65 TOTAL PREVIOUSLY PAID: 0.00 TOTAL CURRENT PAYABLE: 344.65 TOTAL WITHHOLDING: 0.00 TOTAL DEDUCTIBLE: 0.00 TOTAL AMOUNT PAID: 344.65 NOTES BILL IMAGE CONTROL NUMBER- HM2151000173 PLEASE REFERENCE CLAIM NO AND SEND THIS EDP WITH ALL CORRESPONDENCE CAREFULLY DETACH CHECK BEFORE DEPOSITING RETAIN STATEMENT FOR YOUR RECORDS VERIFY THE AUTHENTICITY OF THIS MULTI =TONE SECURITY DDCU ENT CHECK BACKGROUND AREA�C ZANGES COLOR GRADUALLY'FROM TOP *.TO BOTTOMa VIS, 3E 00.4357; CITIBANK .'NA, ONE�ENN' :WAY NEW';,CASTLE; PA. 7 l TL NEW. CASE.., DEc 19720 PO .:BOX 1052 1VIL�tua1 4 AY° MONTGOMERYVILLE;`'PA 18936 lOb2 Fe FAA 6 ON sces PAY# THREE* HUNDRED *FDRTY *FOUR *DOLLARS *SIXTY *FIVE *CENTS* OFFICE NO. B. CODE PAYMENT IDENTIFICATION CHECK NUMBER CHECK DATE 0414 25 T' CLAIM 015455783 -0003 25853395 09/02/10 PAY *$344...65. PAY TO THE ORDER OF CARMEL FIRE DEPARTMENT 2 CIVIC SQUARE CARMEL IN 46032 TWO SIGNATUR ES:REOUIRED IF OVER $500,000 11° 2585339511° -D3 110D 20 910 3870735 ii Provider Number: 1154325579 RECEIVED AUG 1 7 2010 Page 2o( 2 ,'Provider Name: CARMEL FIRE DEPT AMBULANCE AUGUST 06, 2010 DATE(S NUM N PROVIDER OUR O i 0 OTHER A O NT( S MESSAGE OF OF PROCEDURE ME N CHARGEABLE CHARGEABLE CHG LIABILITY 1 LIAR PAID Svc SVGS CODE CODE CHARGE ALLOWANCE AMOUNT :CODE AMOUNT :CODE AMOUNT MEMBER} CODES PATIENT ACCT 201001844 PATIENT: ALBERT KOESKE CLAIM NUMBER: MEMBER ID: 107555922001 MEMBER: ALBERT KOESKE 10711636303 7 09,�i0 i A0425! 3H._GY 023 32 .00 32F.08. 3 00 Ci 260.00:: JSa CLAIM TOTALS 68.93 275.72 CLAIM SPECIFIC MESSAGE(S): We provide administrative claims payment services only and do not assume any financial risk or obligation regarding claims. MESSAGE(S J9040 If you have any questions, call 1- 866- 731 -8080 or the Western District Office 1- 800•-547 -3627 or the Eastern District Office (215) 564 -2131 or write to Customer Service, P.O. Box 890035 Camp Hill PA 17089 -0035. PAYMENT CODES: NON- CHARGEABLE AMOUNT CODES: MEMBER LIABILITY CODES: 023 PREMIERBLUE SHIELD Cl Coinsurance O W'r #did au icn Y A k+,.f.ha faHPrg1Iv m andated NPI compliance date, submit both your NPI and a use, or billing service sends your NPI 0 O 0'.6 5. 7 0 6 2:::7.: Tf', `HIS PNC Bank Nau u onal Assoalioo 60-162 III �...J f 1 i\ JEANNETTE PA 433 031642 BLUE.SHIE4p Aa %nd�errdenr [kmsre efihe Bfue Grors and @j�e Shldd Assoclarlon CHECK NO ltcs 7 74'3 1 PAY TO THE ORDER of -MUST BEi'CRSHED': WITHIN 12 MONTHS° CARMEL FIRE iDEPT AMgULANCE 2CIVIC SQUARE DATE OF CHECK CARMEL, IN.,. 46032--:2584 mo. DAY YR. DOLLARS CENTS 08/06/10 X5:275.72 TWO HUNDRED SEVENTY -FIVR DOLLARS.AND. 72 CENTS PF031642 AUTNORI2ED SIGNATURE HIGHMARK BLUE;SHiELD II ��71,317 0 0: 330 1 I511. PF031642 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. I Payee All �l2m ck C L(E' 1'VZif? 142 Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Total 1 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. h v ALLOWED 20 IN SUM OF b 7 7 17089 42 7,72 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 SO Is 2010 20 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund