159675 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�
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BlueCross BlueShield A Division of I- lealth Care Service Corporation,
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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