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Home My WebLink About159675 05/14/2008 CITY OF CARMEL, INDIANA VENDOR: T361280 Page 1 of 1 0 ONE CIVIC SQUARE R L WILLIAMS -1° CARMEL, INDIANA 46032 846 ENCLAVE CIRCLE CHECK AMOUNT: $71.52 CARMEL IN 46032 CHECK NUMBER: 159675 CHECK DATE: 5/1412008 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 71.52 OTHER EXPENSES I 20 3927 R. L. OR VALUE WILLIAMS 12 -88 740 846 ENCLAVE CIRCLE 62626613 CARMEL, IN 46032 DATE 8 PAY TOTHE ORDER OF C 7� DOLLARS NaflonW FVP 6 MEMO ��G 700006 5`0 6 26 266 4 3 39 2 7 DB365 Rev: 9/03 RP.T5191 Blue Cioss BWeShield f of Texas +j 7D -2382 CHECK NOS 002373438�1� 719 a; ,t C s 4 S:� r•, c A Drv+sion ol'i Health.CarekService Corporation aGMutual.L'egalReserve Comparry r E m }t t "aY j BlusnCross and',BIuwS hid WAssociation. -zf+1 t t w r y'sR *,r t3 PLEASE NEGOTIATE:PROMPTLY r tr,C r a 300 E.Randolph Chicago, IL 60601 5099 ti y -THIS CHECK IS VOID ONE ^YEAR AFTER DATE OF ISSUE v f t� v r ti a s, r DATE CHECK�ISSUED r rt PAYEE NUMBER �,s r te' 3 r r, PAY TO':THE'ORDER OF TXPRrU X04 %z1M1� /08` 356,0'00972T� 00 CARMEL FIRE DEPWRTMENT AM "TG 'r r� Y I '4 7 .r" 2,CARMEL CIVIC SQs r `�S'71 s52 r„ sY CARMEL IN 46032 The .orthern Trust.Com an P y. N 0. t r Oakbrook:Terrace IL r c t I' 2323438 1:07 19 2 38 281:3 149540011- RPT5225 BlueCross BlueShield A Division of I- lealth Care Service Corporation, P, Of Texas a Mutual Legal Reserve Company, 1 PROVIDER CLAIM SUMMARY Independent Licensee of the Blue Cross and Blue Shield Association DATE: 04/11/08 P.O. Box 660044 PROVIDER NUMBER: 000009998 Dallas, "Cexas 75266-0044 Toll Free (800) 451 -0287 CHECK NUMBER: 23734381 TAX IDENTIFICATION NUMBER: 356000972 CARMEL FIRE DEPARTMENT II I 2 CARMEL CIVIC SQ CARMEL IN 46032 ANY MESSAGES WILL BEGIN ON PAGE 1 PATIENT: FLORENCE WILLIAMS THIS IS AN ADJUSTMENT TO A PREVIOUSLY CONSIDERED CLAIM PERF PRV: 000000.00000000009998 IDENTIFICATION NO: 90935- WNA845679875 CLAIM NO: 000080455039304OX PATIENT NO: 200702598 CLAIM TYPE: MR FROM TO PROC AMOUNT ALLOWABLE SERVICES DEDUCTIONS /OTHER AMOUNT D PS* TS CODE BILLED AMOUNT NOT COVERED INELIGIBLE PAID 11/17 11/17/07 05 F A0427 350.00 345.61 4.39 1) 276.49 2) 69.12 11 /1 11/17/07 05 F A0425 12.00 12.00 0.00 9.60 2) 2.40 362.00 357.61 4.39 286.09 71.52 AMOUNT PAID TO PROVIDER FOR THIS CLAIM: $71.52 *DEDUCTIONS /OTHER INELIGIBLE CONTRACT COINSURANCE: 35.76 PORTION ELIGIBLE FOR PAYMENT BY ANOTHER CARRIER /MEDICARE: 250.33 DEDUCTIONS /OTHER INELIGIBLE: $286.09 TOTAL SERVICES NOT COVERED: 4.39 PATIENT'S SHARE: $0.00 PROVIDER CLAIMS AMOUNT SUMMARY NUMBER OF CLAIMS: 1 I AMOUNT PAID TO SUBSCRIBER: $0.50 AMOUNT BILLED: $362.00 I AMOUNT PAID TO PROVIDER: $71.52 AMOUNT OVER MAXIMUM ALLOWANCE: $0.00 RECOUPMENT AMOUNT: $0.00 AMOUNT OF SERVICES NOT COVERED: $290.48 NET AMOUNT PAID TO PROVIDER: $71.52 AMOUNT PREVIOUSLY PAID: $0.00 PLACE OF SERVICE (PS) I TYPE OF SERVICE (TS) 05. OTHER. I F. AMBULANCE SERVICE CLAIM TYPE MR. MEDICARE PRIMARY MESSAGES: RECEIVED ADD 2 2 2008 127,875 356000972T PAGE: 1 OF 2 CONTINUE ON NEXT PAGE Date: 05/01/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: FLORENCE V WILLIAMS ICD -9: 7842 9953 846 ENCLAVE CIRCLE CARMEL, IN 46032 From: 846 ENCLAVE CIR To: ST. VINCENT CARMEL 1 MEDICARE PART B Patient: FLORENCE V WILLIAMS 308268923A 846 ENCLAVE CIRCLE Insurance CARMEL, IN 46032- 2 ANTHEM BC /BS/ 37010 Patient No: 200702598 WNA845679875 YOUR SECONDARY INSURANCE HAS DENIED PAYMENT ON THIS CLAIM. THE AMOUNT SHOWN IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU. Total Amount Total Paid Balance $362.00 $362.00 $0.00 CPT Date Description Charges Credits 11/17/2007 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00 11/17/2007 MILEAGE A0425 $12.00 02/15/2008 MEDICARE PAYMENT $286.09 02/15/2008 ASSIGNMENT MEDICARE $4.39 04/08/2008 PAYMENT $71.52 04/22/2008 BLUE SHIELD PAYMENT $71,52 05/01/2008 REFUND -71.52 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 05/01/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederallD# 356000972 T i my Bill To: FLORENCE V WILLIAMS ICD -9: 7842 9953 846 ENCLAVE CIRCLE CARMEL, IN 46032 From: 846 ENCLAVE CIR To: ST. VINCENT CARMEL 1 MEDICARE PART B Patient: FLORENCE V WILLIAMS 308268923A 846 ENCLAVE CIRCLE Insurance CARMEL, IN 46032- 2 ANTHEM BC /BS/ 37010 Patient No: 200702598 WNA845679875 YOUR SECONDARY INSURANCE HAS DENIED PAYMENT ON THIS CLAIM. THE AMOUNT SHOWN IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU. Total Amount Total Paid Balance $362.00 $433.52 -71.52 CPT Date Description Charges Credits 11/17/2007 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00 11/17/2007 MILEAGE A0425 $12.00 02/15/2008 MEDICARE PAYMENT $286.09 02/15/2008 ASSIGNMENT MEDICARE $4.39 04/08/2008 PAYMENT $71.52 04/22/2008 BLUE SHIELD PAYMENT $71.52 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)) C'a rn b r n V 5 reltc ,'/Ii arnS Total 7 Z 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 MIN VOUCHER NO. WARRANT NO. ALLOWED 20 IN SUM OF 71. 5 Z owroje A 7/. 52- 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 q ture le Cost distribution ledger classification if claim paid motor vehicle highway fund