HomeMy WebLinkAbout194491 02/16/2011 CITY OF CARMEL, INDIANA VENDOR: T359686 Page 1 of 1
t' ONE CIVIC SQUARE ANTHEM BLUE CROSS BLUE SHIELD
CARMEL, INDIANA 46032 CENTRAL REGION -CCOA LOCKBOX CHECK AMOUNT: $270.48
PO BOX 73651 CHECK NUMBER: 194491
CLEVELAND OH 44193-1177
CHECK DATE: 2!16!2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 270.48 OTHER EXPENSES
B1ueCross BhleShield Chi r Randolph 1 PROVIDER CLAI
Chicago, Illinois 6060 1 5099
of Illinois (soo) 972 -8088
DATE: 01/04/11
PROVIDER NUMBER: 1154325579
6
CHECK NUMBER: 54709935
TAX IDENTIFICATION NUMBER: 356000972
CARMEL FIRE DEPARTMENT EIVED 3
2 CARMEL CIVIC SQ
CARMEL IN 46032
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PATIENT: PAUL HERBERT
IDENTIFICATION N0: 81406- XON86027
AGE: 77
CLAIM NO: 0000036457779Z40X PATIENT NO: 201003150
FROM TO PROC AMOUNT AMOUNT DEDUCTIONS /OTHER SERVICES
DATES PS TS* CODE BILLED PAID INELIGIBLE NOT COVERED
12/04- 12/04/10 05 00K A0429 325.00 260.00 65.00 1) 0.00
12/04 12/04/10 05 00K A0425 13.10 10.48 2.62 1 0.00
338.10 270.48 67.62 0.00
AMOUNT PAID TO PROVIDER FOR THIS CLAIM: $279.48 MEDICARE CROSSOVER CLAIM
*DEDUCTIONS /OTHER INELIGIBLE*
CONTRACT COINSURANCE: 67.62
DEDUCTIONS /OTHER INELIGIBLE: S67.62
PATIENT'S SHARE: $67.62
AMOUNT BILLED $338-10
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(1 UATE`pF ISSUE
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PAY TO THE ORDER OF AMOUNT4 3
DEPARTMENT
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The Northern Tr us[ Company
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blue Shield Association
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ANTHEM INSURANCE COMPANIES, INC. 13504
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1351 WILLIAM HOWARD TAFT ROAD
V CINCINNATI, OH 45206 -1775 1 of 4
An independent licensee of the Blue Cross and Blue Shield A5sooiatiOrr 1
Anthem Blue Cross and Blue Shield is the trade name of Anthem insurance Companies, In
Registered Marks Blue Cross and Blue Shield Association
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ANTHEM INSURANCE COMPANIES, INC. CHECK NUMBER 0306779257 DATE 01/26/11
P.O. BOX 37010 PROVIDER NAME CARMEL FIRE DEPT
LOUISVILLE, KY 40233 -7010 ADDRESS 2 CARMEL CIVIC SO
CARMEL IN 46032
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PROVIDER ID NO 000000184493 1154325579
888 -290 -91.60 TAX ID NO XXXXX0972
PAYMENT SUMMARY
GROSS APPROVED CLAIM AMOUNT 420.96 r IRS WITHHELD 0.00
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INTEREST PAID 0.00 STATE WITHHELD 0.00
pro.
t AMOUNT PREVIOUSLY OVERPAID 0.00
NET AMOUNT DUE 420.96 AMOUNT DISBURSED 420.96
RECOUPM ENT BALANCE 0.00
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DETACH CHECK AT PERFORATION BEFORE DEPOSITING.
�►�f ANTHEM INSURANCE COMPANIES, INC. BANK OF AMERICA CHECK NUMBER
M r�r® \Y/ DBA ANTHEM BLUE CROSS AND BLUE SHIELD ATLANTA, GEORGIA 0�0�T 1 257 z
1351 NILLIAM HOWARD TAFT ROAD 0064 1278/0611
CINCINNATI OH 45206 1775 8126AI030122 008493 C003384 m
!$299777. -138 6 i
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PROVIDER ID +N O' TAX PO NO DATE CHECK AMOUNT.r� iir l.. -1 4�� •mxt:
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000000184493 EXXXXXX0972 Or
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PAY EXACTLY �E 3EjE jE 3E 3 E 42 D'. DOLLARS AND 96 CENTS m ➢a
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TO THE ORDER OF o
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CARMEL FIRE DEPT fi
2 CARMEL CIVIC Sq
CARMEL IN 46032
WMEA INSURANCE MMPKNIES, INC.
a
Security features
included.
Delalls'on back.
11 1 :06 1 1 1 2 7661: 3299777b36n°
TOTAL NET AMUUNI UUL: BLUL A�I.
BLUE TRADITIONAL
INSURED OTHER
SERVICE CONTRACTUAL PROVIDER RESP: EX PLlANSI E CODE(S SI
SERVICE DATE(S) CODES POS CHARGE ALLOWED DEDUCTIBLE CO -PAY CO- INSURANCE DIFFERENCE AMOUNT CODEIS� RESPONSIBILITY CODE(S)
NET PAID
AMOUNT
INSURED'S NAME: HERBERT,PAUL R INSURED's ID: XON00 0 0860 27 PATIENT NAME: HERBERT,ELEANOR FOR INQUIRIES CALL:
PATIENT ACCOUNT#: 201003150 CLAIM NUMBER: 2011003OA8246 RECEIVED DATE. 01/03/2011 (866) 594 -0521
SERVICE PROVIDER NAME. CARMEL FIRE DEPT SERVICE PROVIDER ID'. XXXXX0972 EXPL,CD:
12/04/2010 12/04/201.0 A0429 41 325.00 325.00 0.00 0.00 0.00 0.00 0.00 0.00 325.00
12/04/201Q 12/04/2010 A0425 41 13.1.0 13.10 0.00 0.00 0 -00 0.00 0.00 1.0101 13.10
TOTAL: 338.10 338.10 0.00 0.00 0.00 0.00 0.00 0.00 338.10
INTEREST PAID 0.00
TOT AL NET PAID
TOTAL APPROVED AMOUNT 338.10
TOTAL INTEREST 0.00
TOTAL NET AMOUNT DUE: BLUE TRADITIONAL 338.10
GROSS APPROVED CLAIM AMOUNT 420.96
TOTAL INTEREST 0 -00
NET AMOUNT DUE 420.96
EXPL CODES EXPLANATION
MCR MEDICARE BALANCE DUE.
H94 BENEFITS PROVIDED BY ANOTHER INSURANCE CARRIER.
23 THE IMPACT OF PRIOR PAYER(S) ADJUDICATION INCLUDING PAYMENTS AND /OR ADJUSTMENTS.
109 CLAIM NOT COVERED BY THIS PAYER /CONTRACTOR. YOU MUST SEND THE CLAIM TO THE CORRECT
PAYER /CONTRACTOR.
Date: 02/08/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
Bill To: PAUL R HERBERT ICD -9: 7295
12978 PORTSMOUTH DR
CARMEL, IN 46032
From: 12978 PORTSMOUTH DR
To: ST. VINCENTS HOSPITAL CARMEL
I MEDICARE PART B
Patient: ELEANOR HERBERT 208262340A
12978 PORTSMOUTH DR Insurance
CARMEL, IN 46032 2 ANTHEM BC/BS/ 37010
Patient No: 201003150
XON000086027
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
$338.10 $608.58 270.48
CPT
bate Description Charges Credits
12/04/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
12/04/2010 MILEAGE A0425 $13.10
01/13/2011 BLUE SHIELD PAYMENT $270.48
01/27/2011 PAYMENT $67.62
02/03/2011 BLUE SHIELD PAYMENT $338.10
02/08/2011 REFUND -67.62
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 02/08/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MEDSVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
Bill To: PAUL R HERBERT ICD -s: 7295
12978 PORTSMOUTH DR
CARMEL, IN 46032
From: 12978 PORTSMOUTH 9R
To: ST. VINCENTS HOSPITAL CARMEL
1 MEDICARE PART B
Patient: ELEANOR HERBERT 208262340A
12978 PORTSMOUTH DR Insurance
CARMEL, IN 46032 2 ANTHEM BC /BS/ 37010
Patient No: 201003150
XON000086027
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
$338.10 $338.10 $0.00
CPT
Date Description Charges Credits
12/04/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
12/04/2010 MILEAGE A0425 $13.10
01/13/2011 BLUE SHIELD PAYMENT $270.58
01/27/2011 PAYMENT $67.62
02/03/2011 BLUE SHIELD PAYMENT $338.10
02/08/2011 REFUND -67.62
02/08/2011 REFUND 270.98
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
�H121 G'/Y)�(F_ Jl1��lGL Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
&r
Total p) Q
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
ftfi�`y�le/n, c O 55 ,81 c�SGU IN SUM OF 2 70 y 7
D. /3oX 23 5 Z
OJekT -Janal, C9 q�4I q3- 77
c?70,Y
ON ACCOUNT OF APPROPRIATION FOR
AM46 awe f -un (2(&o A2AK0
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
I N
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund