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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 Connect with vendors at our e- Match Expo! For dates, locations and registration, visit our online Education Center at wtvw.bcbsil.com /provider. III llll9lllllllll�lllllll IIIIIII�II II IIII I I IIIiI 011 ANY MESSAGES WILL APPEAR ON PAGE 3 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 $338-10 u :LA r$ 7n F m 06365 Rev: 9/03 3 _r i C 4 1E00161L0460612108 x a r�i Kaa� ct fFq'� a 4 ueSlueld f r �111eCY0sS Bl t p054706935 R y D 2382 r CHIC r �p Of If1111015 a cr r i& n r., sh`; r 7�g d \�-'"iarr t ,tka f,,y a fi a A::Divasion ofHealth Caro.Se rvice Carporatron a;Mutu Lbgal�'!CompanY 61 Roserve anglndependent Lieansee:pf the +e wh a trp�Ep'SE NEGOTIATE PROMPTLY 1 tj 61ue Cross acid 81ue Shield Association r THIS CHECK !S VolD YEAR AFTER (1 UATE`pF ISSUE hPAI EE NUMBER t S00 East Randolph DATE CHECK ISSUED 3r 1 p 1 r 3 Ch+cago Illinois 60601 5099 HCMS3 L PAY TO THE ORDER OF AMOUNT4 3 DEPARTMENT CARMEL: F IR_E E CARMEL. C SQ f 2.;.,CARMEL CIVI IN 4bD32 S F t The Northern Tr us[ Company 'Chicago; IL ,•'Rayatile'7Through `Dak4taok�Terrace, IL a° 547DD93511• Lo07 19 238 281. 3 L 195400��° blue Shield Association 0126AI030122 008493 ANTHEM INSURANCE COMPANIES, INC. 13504 u ff\pm) DBA ANTHEM BLUE CROSS AND BLUE SHIELD r�� V 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 �I'IIi1Il11lllllllf'111�1I1 #185999999493/DF9# N05ECE .ED FE 2011 o CARMEL FIRE DEPT o 2 CARMEL CIVIC SQ r CARMEL IN 46032 w 0 0 m r to C, N 0 N O r �k 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 a® 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 t>® 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 rraoaoia ism rtmn: nni® mwltlr r� 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 r PROVIDER ID +N O' TAX PO NO DATE CHECK AMOUNT.r� iir l.. -1 4�� •mxt: �n c 000000184493 EXXXXXX0972 Or 0 PAY EXACTLY �E 3EjE jE 3E 3 E 42 D'. DOLLARS AND 96 CENTS m ➢a ZZ1 TO THE ORDER OF o 0 31 C17 N r-n mml Zcc 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