The URL can be used to link to this page

Home My WebLink About194612 02/16/2011 CITY OF CARMEL, INDIANA VENDOR: 365079 Page 1 of 1 ONE CIVIC SQUARE ELEANOR HERBERT CHECK AMOUNT: $67.62 CARMEL, INDIANA 46032 12978 PORTSMOUTH DRIVE CARMEL IN 46032 CHECK NUMBER: 194612 CHECK DATE: 2/16/2011 DEPARTMENT ACCOUNT PO NU INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 67.62 OTHER EXPENSES Date: 02/08/2011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032 (317)571 -2605 FederalID# 356000972. �Jp H i BiliTo: PAUL R HERBERT ICD -9: 7295 12978 PORTSMOUTH DR CARMEL, IN 46032 From: 12978 PORTSMOUTH DR 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: XON000086027 YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN. THIS AMOUNT 1S YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW_ THANK YOU. Total Amount Total Paid Balance $338.10 $676.20 338.10 CPT bate Description Charges Credits 12/04/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 12/04 "/2010 MILEAGE AQ425 $13.10 01/13/2011 BLUE SHIELD PAYMENT $270.48 01/27/2011 PAYMENT $67.62 02/03/2011 BLUE SHIELD PAYMENT $338.10 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 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 1 MEDICARE PART B Patient: ELEANOR HERBERT 208262340A 12978 PORTSMOUTH DR Insurance CARMEL, IN 46032 2 ANTHEM BC /BS/ 37010 Patient No: 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 S- 270.48 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 $270.48 0112712011 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 ry Return this portion with your payment Payable To: CARMEL FIRE DEPARTMENT 201003150 PAUL R HERBERT RECEIVED JAN 2 7 2011 $67.62 Run Date s -7 12/04/2010 Amount Paid E LEANO R 4 H 4516. 1 ,k �460327V�' �'k��Vlv,, k�i :,ARMEL.W 863 3 4 ?D �8 'p. -tV DATE' A Y Z 0 60"ks FOR -2 211- 4 5 .16 BlueCrc ►ss BlueShield Chicago Illinois 60601 5099 1 PROVIDER SUMMARY of Illinois (8()0) 972-8088 DATE: 01/04/11 PROVIDER NUMBER: 1154325579 CHECK NUMBER: 547DO935 TAX IDENTIFICATION NUMBER: 356000972 CARMEL FIRE DEPARTMENT I 20HO 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 wWW,bcbsi1xom1provider. I191 IIII�I Illlllll�lllllll Il�llll�ll II 1111 i I !1111 III ANY MESSAGES WILL APPEAR ON PAGE 1 PATIENT: PAUL HERBERT IDENTIFICATION N0: 81408- XON86027 AGE: 77 CLAIM NO: 0000036457779Z40X PATIENT NO: FROM TO PROC AMOUNT AMOUNT DEDUCTIONS /OTHER SERVICES DATES PS TS* CODE BILLED PAID INELIGIBLE NOT COVERED 12/04 12/04/10 05 OOK A0429 325.00 260.00 65.00 t 1) 0.00 12/04 12/04/10 05 OOK A0425 13.10 10.48 2.62 1 0. DO 338.10 270.48 67.62 0.00 AMOUNT PAID TO PROVIDER FOR THIS CLAIM: $270.48 MEDICARE CROSSOVER CLAIM *DEDUCTIONS /OTHER INELIGIBLE CONTRACT COINSURANCE: 67.62 DEDUCTIONS /OTHER INELIGIBLE: $67.62 PATIENT'S SHARE: $67.62 AMOUNT BILLED. $338.10 15� r i x i'' r +d s 7sw aYi y a I �z•n `w r DB365ReV 911)3 y r r Ifa ft r+m r, t t} x' t ��v f i I� t I�h r Bluecras HECK s BltieShield 0054�000�5 tz CNO V�r O� I11ino1S t 70 2382 719 �x m a ti ti fi p;Dw+siomof_Health Care Serv�ca Corporation,. a;MUtuaLLegal Reserve +ComPanY amAndependent Clcanseeof the pLEA'SE NEGOTIATE PROh7PTLY .''.Blue Cross and Blua Shield Assaciat+on THIS'CNECK IS VOlOAONE +(19 YEAR AFTER DATE;OF ISSUE" Y PAEE NUMBER,' i 300 East Randalph PATE CHECK,ISSUED Ch 111indis sosot sole li CM S3 1 0 1 15 4 3 2 5 57 9 01/04�/1� Fy. P AY4 TO THE QRDER,OF nMauNT t 4 ARTME.NT 27f0 CARMEL.FIR.E DEP 2.CAR'MEL CIVIC"SQ f IN:.:6'032 v CARKE`L r The,Northern Trust Company F Cl: :=Payable.: Through Oakbrook Terrace, IL uo54700�35 +t' t:0 7Lci 2382810 3g5 LIDO 110 N',� .suss and oiue Shield Assoaauun 0126A1030122 008493 ANTHEM INSURANCE COMPANIES, INC. 13504 DBA ANTHEM BLUE CROSS AND BLUE SHIELD them, r v0 19 1351 MI HD T ROAD g gy g VVV WI CINCINNATI, 4520 ON 45206-177177 5 1 of 4 An independent licensae of the Blue Cross and Blue Shield Assocration. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc_ Registered Marks Blue Cross and Blue Shield Association Ifl(�LILJI,��lfll�f�lfil �-t gq #BNNCQXF RE C E I VE D Y ED F G B #165999999493/DF9# NOS o CARMEL FIRE DEPT 2 CARMEL CIVIC SQ w CARMEL IN 46032 0 0 CID 41 L4 0 N O r 0 >K ANTHEM INSURANCE COMPANIES, INC. CHECK NUMBER 0306779257 DAIS 01/26/11 P.O. BOX 37010 PROVIDER NAME CARMEL FIRE DEPT LOUISVILLE, KY 40233 -7010 ADDRESS 2 CARMEL CIVIC SO CARMEL IN 46032 PROVIDER ID NO 000000184493 1154325579 888- 290 -9160 TAX ID NO XXXXX0972 r� PAYMENT SUMMARY GROSS APPROVED CLAIM AMOUNT 420.96 r IRS WITHHELD 0.00 INTEREST PAID 0.00 l STATE WITHHELD 0100 f ®o 1 AMOUNT PREVIOUSLY OVERPAID 0.00 NET AMOUNT DUE 420.96 f AMOUNT DISBURSED RECOUPMENT BALANCE 0.00 r� a� ^er• err DETACH CHECK AT PERFORATION BEFORE DEPOSITING 'pg,, ANTHEM INSURANCE COMPANIES, INC. BANK OF AMERICA CHECK NUMBER Aii Ji 8 e r•� \1�/ DSA ANTHEM BLUE CROSS AND BLUE SHIELD ATLANTA, GEORGIA 03067792 57 GGG%%%JLit v 1351 WILLIAM HOWARD TAFT ROAD 0064-1278/0611 CINCINNATI; OH' 45206 -1775 0126AIDSOIZZ- 008493 3299777138 m C003384 I r1D� PROVIDER ID NO TAX ID NO DATE CHECK AMOUNT, t x��c r sr tai bin f 00000018449 XXXXX0972 01/26/11 5 *420 96 z oc n on PAY EXACTLY 1E 3E 3E3EjE #4ZD AND 96 CENTS. A7 a Z TO THE ORDER OF: �zj P r-n =0F CARMEL FIRE DEPT f= 2 CARMEL CIVIC SQ CARMEL IN 46032 *MITE 1 INSURA E P NIES, INC_ T a a Security lectures included_ .Details on back: 11 °030677925711° IMP, L1127881a 3299777�38��° BLUE TRADITIONAL SERVICE DAT E(S) SERVICE POS CHARGE INSURED OTHER ALLOWED DEDUCTIBLE CO -PAY CO- INSURANCE CONFERENCAL'PR AMOUNT T ECODELS) RESPONSIBILITY EXP(JAN) NET PAID CODES DIFFERENCE AMOUNT CODEIS) AMOUNT CODE(S) INSURED'S NAME: HERBERT,PAUL R INSURED'S ID: XON000086027 PATIENT NAME: I IERBERT,ELEANOR FOR INQUIRIES CALL: PATIENT ACCOUNT# 201003150 CLAIM NUMBER, 20110031PA8246 RECEIVED DATE: 01103/2011 (866) 594 0521 SERVICE PROVIDER NAME CARMEL FIRE DEPT SERVICE PROVIDER 10 XXXXX0972 EXPLCD'. 12/04/2010 12/04/ZOLO A0429 41 325.00 13. 325. 0.00 0.00 0.00 o.Qa o.00 0.00 325.00 12/04/zolo 12%04/2010 A04ZS 41 13.10 13.10 4.00 0.00 0.00 0.00 0.00 0.00 13.10 TOTAL: 338.10 338.10 0. -00 0.00 0.00 O.QO 0.00 0.00 338.10 INTEREST PAID 0.00 O.T.AL�IELPAI 3 3& 10--j 0 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. `1 Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 207 (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 I Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) /Y/ e 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 IN SUM OF 6 Z 6 Z 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 .,ea- Jry 20 Signature Cost distribution ledger classification If Title claim paid motor vehicle highway fund