156084 02/06/2008 CITY OF CARMEL, INDIANA VENDOR: T360782 Page 1 of 1
d ONE CIVIC SQUARE MICHAEL ANSTED
CARMEL, INDIANA 46032 64 DRUID HILL CT CHECK AMOUNT: $60.61
CARMEL IN 46032
CHECK NUMBER: 156084
CHECK DATE: 21612008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1 102 5023990 60.61 REFUND
Remittance Advice Check
Date: 01/03/2008
Provider Number: 526473
Provider Name: CARMEL FIRE DEPARTHENT
Check Date: 01 /03/2008
Check Number: 2423136
Check Amount: e96.61
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Please retain this portion for your records
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FIRST HEALTH LIFE AND HEALTH INSURANCE. CC).
A COVENTRY HEALTH CAPE PLAN
14955 ,Heatnrow orresl Parkway
Houston TX 7
15442 1 M B 0.360 950 63 15442
CARMEL FIRE DEPARTMENT
2 CIVIC SQUARE
CARMEL IN 46032 -7543
IIIIIIIIII lip 11 1111i„II
If you would like to return this check please mail to:
FIRST HEALTH LIFE HEALTH
Alin: The Recovery Dept.
120 East Kensinger Dr
Cranberry Twp PA 16066
RECEIVED JAN I �I�tJg
If you would like to make a refund please mail to:
FIRST HEALTH LIFE HEALTH
PO Box 6495
Carol Stream IL 60197 -6495
COV001 PPDVJ3 COV00110.RTP 9501 2063 CKP1R 146
THE AGIf CF THI '-HEf I< CONTP.IhS AN ARTIEICIAI WATERIOARK HC)LD AT AN ANGLE TO VIE'N 1 F-EASE FO D ON PERFORATION AND DETACH H RE t THIS CHECK, IS PRINTED 0111 COLORED BACKGROUND
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Page 1 of 1 I I
Remittance Advice Summary FIRST I- IEALTI -I LIFE AND HEALTH INSURANCE CO. A COVENTRY I- IEALTH CARL PLAN
Provider 526473: CARMEL FIRE DEPARTHENT NPI (Not on file. Please Submit) Pay Date: 01/03/2008
Patient Name: Ansted,Michael, Member 801268539 *01 Claim 3838807 Carrier: FIRST HEALTH CARRIER
Account 200702042 Date Received: 10/29/07 Auth. Network /Division: PRIMARY CARE PHYSICIAN
Place of Service: AMBUL LAND Processed Date: 01/03/08 Claim Provider: CARMEL FIRE DEPARTHE Product: PFFSI -MAFFI
THIS CLAIM BACKED OUT CLAIM 1730220194 WHICH WAS REPLACED BY CLAIM 3838808.
Service Dates Proc Mod DRG/ Procedure Cap Total Allowed Ineligible Inelig COB Deductible CoPay Mbr Mbr Mbr Adj Paid
From To Code Cd APC Description Charges Amount Amount DC DC Amount Amount Coins. Respons DC RC Amt
09/12/07 09/12/07 A0429 RH AMBULANCE N $300.00 $291.04 -$8.96 1300 $0.00 $0.00 $58.21 $58.21 09206 $232.83
09/12/07 09/12/07 A0426 RH AMBULANCE N $48.00 $12.00 $36.00 1121 $0.00 $0.00 -$2.40 -$2.40 -$9.60
Check 2423136 Claim Totals $348.00 $303.04 $44.96 $0.00 $0.00 $60.61 $60.61 $242.43
Patient Name: Ansted,Michael, Member 801268539 *01 Claim 3838808 Carrier: FIRST HEALTH CARRIER
Account 200702042 Date Received: 12/31/07 Auth. Network /Division: PRIMARY CARE PHYSICIAN
Place of Service: AMBUL LAND Processed Date: 01/03/08 Claim Provider: CARMEL FIRE DEPARTHE Product: PFFSI- MAFI-I
THIS CLAIM REPLACED CLAIM 1730220194 WHICH WAS BACKED OUT BY CLAIM 3838807.
Service Dates Proc Mod DRG/ Procedure Cap Total Allowed Ineligible Inelig COB Deductible CoPay Mbr Mbr Mbr Adj Paid
From To Code Cd APC Description Charges Amount Amount DC DC Amount Amount Coins. Respons DC RC Amt
09/12/07 09/12/07 A0429 RH AMBULANCE N $300.00 $291.04 $8.96 1300 $0.00 $0.00 $0.00 $0.00 09206 $291.04
09/12/07 09/12/07 A0425 RH GROUND MIL N $48.00 $12.00 $0.00 1300 $0.00 $0.00 $0.00 $0.00 $48.00
Check 2423136 Claim Totals $348.00 $303.04 $8.96 $0.00 $0.00 $0.00 $0.00 $339.04
Provider Summary: Total Allowed Ineligible Deductible CoPay Mbr Mbr Paid
Charges Amount Amount Amount Amount Coins. Respons Amt
Non statistical Claims Line Totals: $0.00 $0.00 $36.00 $0.00 $0.00 $60.61 $60.61 $96.61
Provider Claims Totals: $0.00 $0.00 $36.00 $0.00 $0.00 $60.61 $60.61 $96.61
Provider Check Summary:
Check Number Check Date Check Amount
2423136 01/03/08 $96.61
Remark Code Descriptions are located at: http://www.wpc-edi.com/codes/remittanceldvice
Ineligible Disposition Codes (Remark Codes) Description (Inel DC, COB DC, ADJ RC):
1121 (M53) REJ -NR -UNITS ADJUSTED TO REFLECT THE ALLOWED AMOUNT FOR THE CODE BILLED
1300 INEL- EXCEEDS MEDICARE ALLOWABLE. DO NOT BILL MEMBER.
09206 PROV:RECEIVED REQUESTED MISSING INFORMATION
Ate 2008
COV001 PPDVJ3 COV00110 RTP 950 2084 CKP1R 146
MICHAEL E. AMSTED 02 -93 zo 1 17006 2740 6 0 3.2
117006104
64 DRUID HILL CT. J
CARMELRMELIN 46032 -1509 ca7E
PAY T^ TH-
DOLLARC
FIRST NINDIIS. INDIANAN BA NK n� (�fAop /'A'I wp
MEMO Y 6
6.032 E
Date: 01/18/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
Bill To: MICHAEL E ANSTED ICD -9: 2930 78093 78079
64 DRUID HILL CT
CARMEL, IN 46032
From: 64 DRUID HILL CT
To: ST. VINCENT- INDPLS
1 ADVANTRA FREEDOM
Patient: MICHAEL E ANSTED 801268539 -01
64 DRUID HILL CT Insurance
CARMEL, IN 46032 2
Patient No: 200702042
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
$348.00 $408.61 -60.61
CPT
Date Description Charges Credits
09/12/2007 BASIC LIFE SUPP- EMERGENCY g0429 S300.00
09/12/2007 MILEAGE A0425 $48.00
11/09/2007 MEDICARE PAYMENT $242.43
11/09/2007 ASSIGNMENT MEDICARE $44.96
12/04/2007 PAYMENT. $60.61
01/15/2008 ASSIGNMENT MEDICARE -36.00
01/15/2008 MEDICARE PAYMENT 596.61
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 01/18/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal io# 356000972
Bill To: MICHAEL E ANSTED ►CD -9: 2930 78093 78079
64 DRUID HILL CT
CARMEL, IN 46032
From: 64 DRUID HILL CT
To: ST. VINCENT INDPLS
ADVANTRA FREEDOM
Patient: MICHAEL E ANSTED 801268539 -01
64 DRUID HILL CT Insurance
CARMEL, IN 46032 2
Patient No: 200702042
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
$348.00 $348.00 $0.00
CPT
Date Description Charges Credits
09/12/2007 BASIC LIFE SUPP- EMERGENCY A0429 $300.00
09/12/2007 MILEAGE A0425 $48.00
11/09/2007 MEDICARE PAYMENT 5242.43
11/09/2007 ASSIGNMENT MEDICARE $44.96
12/04/2007 PAYMENT $60.61
01/15/2008 ASSIGNMENT MEDICARE -36.00
01/15/2008 MEDICARE PAYMENT $96.61
01/18/2008 REFUND -60.61
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))
S
.7
4
v
f' s
i
Total �p
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
ON ACCOUNT OF APPROPRIATION FOR
4 iece Lt—fid�/�Q A21 i
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
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund