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Home My WebLink About158269 04/15/2008 0i. CITY OF CARMEL, INDIANA VENDOR: 356246 Page 1 of 1 ONE CIVIC SQUARE AETNA CHECK AMOUNT: $275.62 CARMEL, INDIANA 46032 PO BOX 981107 EL PASO TX 79998 -1107 CHECK NUMBER: 158269 CHECK DATE: 4/15/2008 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 275.62 REFUND i r BROAD S PIRE a Crawford Compny AUDIT OF MEDICAL CHARGES Patient Name: PATRICIA MASON Billing ID 888 -H- 8158280 SSN: 317 -60 -4606 FOR Date: 03/20/2008 Claim /Seq 534331482 Date of Accident: 01/09/2008 Employer Name: GLAXOSMITHKLINE -TPA Unique Image 0:20664198 Patient Ref#: Adjustor: RJB Page: 1 This audit was prepared in compliance with Usual and Customary fees for the state of Indiana. CLAIMANT: EMPLOYER: CARMEL FIRE DEPARTMENT PATRICIA MASON GLAXOSMITHKLINE -T 12946 PORTSMOUTH DRIVE PO BOX 13398 2 CIVIC SQ CARMEL, IN 46032 -0000 RESEARCH TRIANGLE PA, NC 27709 -000 CARMEL, IN 46032 2584 PROVIDER: TAX ID 35 6000972 CARRIER: 200 CARMEL FIRE DEPARTMENT Old Republic Insurance Company R CIEIVED MAR 2, 7 2 CIVIC SO P.O. Box 789 CARMEL. IN 46032 2584 Greensburg, PA 15601 Date of Adjusted Submitted Diag. Actual Maximum E O M B Service Code Code Description Units Code Charges Allowable Codes 01/09/2008 A0429 A0429 AMBULANCE SERVICE BLS EMERGENCY TRAM: 1 1 300.00 300.00 112 -003 01/09/2008 A0425 A0425 GROUND MILEAGE PER STATUTE MILE 1 1 6.25 6.25 Total Actual Charges 5306.25 Reduction Amount (Please Do Not Balance Forward Reductions) $0.00 Contracted Discount Reduction $0.00 T R Iount S306.25 Summary of Codes Diagnostic Codes: (1) 789.07 ABDOMINAL PAIN, GENERALIZED (2) 786.52 PAINFUL RESPIRATION (3) 729.5 PAIN IN SOFT TISSUES OF LIMB (4) E813.0 MOTR VEH COLLISION W /OTH VEH -INJR MV DRIVER E O M B Codes: 112 -003 THE PRIMARY PROVIDER IS A NON CONTRACTED PROVIDER. (Continued on next page) L- VERIFY THE AUTHENTICI OF THIS MULTI= TONE'_SECURITY'DOCUMENT CHECK:BACKGROUND:AREA CHANGES COLOR:'ORADUALLY;FROM TOP TO BOT TOM rJ '-i'�-r�T��T+ �.i -'•C FA [w'ECnrlw Bro�dspl�eervleas �in� on b�t�a of Ofd Rapubhc CLAIM CHECK NUMBER 280017759 641276 PAlD'ON'B FHALF O G F is Old Repubhc1nsurance Company ntro Disbursement esenPe Aa. 32991 Void ffsnpLp d for p yment .'Bank of Amerrca; N A vnthin "100 days after dat of issue ".`ISSUED AT.'' anta, De Ge'prgia :Atl kalb:Co unty PLANTATION TO THE AMOUNT ORDER CARMEL`FIRE DEPARTMENT DATE'ISSUED, *30 March 21.2008 6.2`5.... AMOUNT. Three hundred'six and 25/100 Dollars CARMEL DEPARTMENT PAYMENT FOR Medical Transportation 21"C:IVIC:SO Treatment dates: `1/09/2008 1'/09/2008 CARMEL, IN .46032 2584 .CLAIM NUMBER POLICY NUMBER LOSS DATE :534331482 MWC11514500 01/09/2008 INSURED COMPANY USE ONLY GLAXOSMITHKLINE -TPA CLAIMANT CUSTOMER CLAIM NUMBER PATRICIA MASON BY Ila2830DL7759 1:06 LL1, 27881: 329 9Lh L67611a P.O. BOX 981107 Ex PLANATION OF EENEFr S /A etna EL PASO, TX 79908 -1107 1 USA Please Retain for Future Reference 008172 J280DUA2 022983 CITY OF CARMEL FIRE DEPT. PIN: 0005745100 Check No: 08325/047949587 Page 2 of 3 Date Printed 03/04!2008; CITY OF CARMEL FIRE DEPT. Tax Identification Number XXXX.XXXX0972' 2 CIVIC SQ Check:Number. 08325/047949587 CARMEL IN 46032 -2584 Check '...Z$621 Notes: The benefits listed below reflect yourportion of this payment. Patient Name: PATRICIA L MASON (Self) Claim ID: ENPABOKGF00 Recd: 02/25/08 Member ID: VV006480678 Paiient Account: 200800167 Member: PATRICIA L MASON DIAL: 78907 78652 7295 Group Name: SMITHKLINE BEECHAM CORPORATION, A GLAXOSMITHKLINE Group Number 885594 -10 -004 CA P1 <BIO Product: Aetna Choice® POS II Network ID: 00000 Aetna Life Insurance Company SERVICE PL' SERVICE NUM SUBMITTED ALLOWABLE COPAY': NOT SEE DEDUCTIBLE Co PATIENT PAYABLE DATES CODE Svcs CHARGES AMOUNT AMOUNT PAYABLE: REMARKS INSURANCE RESP AMOUNT 01/09108 41 A0429 I 1 300.00 I 30.00 0000 270.00 1 01109108 41 A0425 1 6.25 0.63 0.63 5 62 TOTALS 306.251 I 30.63 30.63 275.62 >ISSUED' AMT $275;62 For Questions Regarding This<Clarm F.O. BOX 981109 EL °A50 TX 7ss98 -1109 I otal Patient Responsiblllty:' $30.63 CA LL (888) 632 =3862 ;FOR ASSISTANCE Clair; Payment: $275,,62 Note :Lill Inquiries should: reference thA ID nrirnberabove for prompt response P .Q. BOX 981107 CLAIM. PA YMENT PASO, T 7 9998 -1161 1 SP, Please Retain far Future Reteience 008172 J280MM2 822982 CITY OF CARMEL FIR= DEPT. PIN: 0005745100 CITY OF CARMEL FIRE DEPT. 2 CIVIC SQ CARMEL IN 46032 2584 {rLr{rilrrllrrrrtl{ grit{rr lt{ t {r!r{rr {rrlrrillrtrtr {t{tlrr{I I`� .G:1- I tYL,.. fix W7AIVB{.7!�'E t I: i:l 't r- 'ZNffi.1a E_.. AemeCiie�Insurence .CompemyorenAffilieied Check�NO :�<7 .794�J87 ...Compenv as Aaerit`(or.5 ecified: Payer(s) p 'Seq:No: 000010644 Acct:- :38208325_ ...P.O. BOX- 981.107 EL PASO TX '79998-1107 °11SA 1r` rlv',�RdP W y 6 372 liI M .e a r e dl��i' +i IIIIUCinI+M 4 PAYERS MULTIPLc+ M w a «r r r o II y x aMi,d 71 `A% 8x H �r i,• f f� c �r all a k JV i IHI i lUhi'*;i t,7 PAS ��II'I ,4 Twen One�ollars and 22I�004 I a J�.�' r1 i'p TOTHE 4 1r,„,arc w G IHlld'.r'�Iu4� a� r �VO1D �:F7` R ?YiR r^"whl r t d TYY0" 5RMEI FIR DEPT 621 22 i y 2 CIVIC SQ i^ o ,,,rv�a1 1 ORDERBF ;bARMECINW03P 2584q r !�b�u n t� '1 k�. �e )gyp P C" I k! lly .dnr'' SIC 1 lit, Jw Citibank `'N A New.Cestle ,DE 18720, �Z� uS �br�, �ssllo -ozJ INR a \fl"L`�,'1 %rF'"•� IId� r a l ;'i p III f� 5 "a 7 n•.:;.c, D 3 b:ll 0" 2 0° 9 `o 3:8'",2 (3 fl 3�'2 5.110 Date: 04/07/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Al A, Bill To: PATRICIA MASON ICD -9: 78907 78652 7295 E8130 12946 PORTSMOUTH DRIVE CARMEL, IN 46032 From: SPRINGMILL &DORSET BLVD To: CLARIAN NORTH 1 AETNA US HEALTHCARE /981106 Patient: PATRICIA MASON W00648067801 12946 PORTSMOUTH DRIVE Insurance CARMEL, IN 46032- 2 Patient No: 200800167 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 $306.25 $306.25 $0.00 CPT Date Description Charges Credits 01/09/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00 01/09/2008 MILEAGE A0425 $6.25 03/14/2008 COMMERCIAL INSURANCE PAYMENT $275.62 03/28/2008 COMMERCIAL INSURANCE PAYMENT $306.25 04/07/2008 REFUND 275.62 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 04/07/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: PATRICIA MASON ICD -9: 78907 78652 7295 E8130 12946 PORTSMOUTH DRIVE CARMEL, IN 46032 From: SPRINGMILL &DORSET BLVD To: CLARIAN NORTH AETNA US HEALTHCARE /981106 Patient: PATRICIA MASON W00648067801 12946 PORTSMOUTH DRIVE Insurance CARMEL, IN 46032- 2 Patient No: 200800167 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 $306.25 $581.87 275.62 CPT Date Description Charges Credits 01/09/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00 01/09/2008 MILEAGE A0425 $6.25 03/14/2008 COMMERCIAL INSURANCE PAYMENT $275.62 03/28/2008 COMMERCIAL INSURANCE PAYMENT $306.25 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995) r 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 k4 fi a Purchase Order No. 0 -13 0 :Z Terms X 7 9 9 9 Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) /2 Total a 76,692 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 c3 7�5 9�F//0 7 75. e�o Z ON ACCOUNT OF APPROPRIATION FOR A &o 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 20 0 Si nat re Cost distribution ledger classification if Title claim paid motor vehicle highway fund