165010 10/16/2008 CITY OF CARMEL INDIANA VENDOR: T362012 Page 1 of 1
ONE CIVIC SQUARE MYRTLE YORK
CARMEL, INDIANA 46032 14360 GREENBELT CT CHECK AMOUNT: $150.00
CARMEL IN 46033 CHECK NUMBER: 165010
CHECK DATE: 10/16/2008
D EPARTMENT ACCOUNT PO NUMBER INV NUMBER AMOUNT DESCRIPTION
,�_02 5023990 150.00 OTHER EXPENSES
Page 1 of 1 I I
Remittance Advice Summary COVENTRY HEALTH AND LIFE INSURANCE COMPANY A COVENTRY HEALTH CARE PLAN
Provider 526473: CARMEL FIRE DEPARTHENT NPI Pay Date: 09/25/2008
Patient Name: York,Myrtle,F Member 801153554'01 Claim 9449593 Carrier: CH &L CARRIER
Account 200801788 Date Received: 08/04/08 Auth. Network /Division: PRIMARY CARE PHYSICIAN
Place of Service: AMBUL LAND Processed Date: 09/25/08 Claim Provider: CARMEL FIRE DEPARTHE Product: PFFSI -MACHL
THIS CLAIM BACKED OUT CLAIM 1821725445 WHICH WAS REPLACED BY CLAIM 9449594.
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
07/21/08 07/21/08 A0427 RH AMBULANCE N $350.00 $350.00 $0.00 $0.00 $150.00 $0.00 $150.00 09274 $200.00
07/21/08 07/21/08 A0425 RH GROUND MIL N $37.50 $37.50 $0.00 $0.00 $0.00 $0.00 $0.00 $37.50
Check 1810205 Claim Totals $387.50 $387.50 $0.00 $0.00 $150.00 $0.00 $150.00 $237.50
Patient Name: York,Myrtle,F Member M 801153554'01 Claim M 9449594 Carrier: CH &L CARRIER
Account 200801788 Date Received: 08/07/08 Auth. Network /Division: PRIMARY CARE PHYSICIAN
Place of Service: AMBUL LAND Processed Date: 09/25/08 Claim Provider: CARMEL FIRE DEPARTHE Product: PFFSI -MACHL
THIS CLAIM REPLACED CLAIM 1821725445 WHICH WAS BACKED OUT BY CLAIM 9449593.
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
07/21/08 07/21/08 A0427 RH AMBULANCE N $350.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 09274 $350.00
07/21/08 07/21/08 A0425 RH GROUND MIL N $37.50 $37.50 $0.00 $0.00 $0.00 $0.00 $0.00 $37.50
Interest calculated at 5.125% annually for 19 DAYS $0.40
Check M 1810205 Claim Totals $387.50 $387.50 $0.00 $0.00 $0.00 $0.00 $0.00 $387.50
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 $0.00 $0.00 $150.00 $0.00 $150.00 $150.00
Provider Claims Totals: $0.00 $0.00 $0.00 $0.00 $150.00 $0.00 $150.00 $150.00
Provider Check Summary:
Check Number Check Date Check Amount
1810205 09/25/08 $150.40 Total Interest Paid $0.40
Ineligible Disposition Codes (Remark Codes) Description (Inel DC, COB DC, ADJ RC):
09274 GENL: ER /AMBULANCE COPAY REMOVED BASED ON INPATIENT ADMISSION
T% a'A
Please direct claim questions for Advantra Freedom to 1- 800 713 -5095. Resubmissions should be sent to PO Box 7154, London, KY 40742. Appeals should be submitted to Advantra Freedom, PO Box
7157, London, KY 40742. Please visit directprovider.com for up -to date information.
COV001 PPFUGZ COV00123.RTP 17891 3989 CKP1R 144
Remittance Advice Check
Date: 09/25/2008
Provider Number: 526473
Provider Name: CARMEL FIRE DEPARTHENT
Check Date: 09/25/2008
Check Number: 1810205
Adva ntra Check Amount: $150.40
fj Leedom Please retain this portion for your records
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oueii#ty National Metlicate:P.r to
COVENTRY HEALTH AND LIFE INSURANCE COMPANY
A COVENTRY HEALTH CARE PLAN Feeoreru�Ce plan Payer ID 23152 for In &t Prof, ciauns.::s
14955 Heathrow Forrest Parkway a11df�A tt10 f AdVartfraceedpm is NGS #9 #se'confusei
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CARMEL FIRE DEPARTHENT
2 CIVIC SQUARE
CARMEL IN 46032 -7543
If you would like to return this check please mail to:
COVENTRY HEALTH AND LIFE INSURANCE
Attn: The Recovery Dept.
120 East Kensinger Dr
Cranberry Twp PA 16066
RIC IV OCT 0 7 2008
If you would like to make a refund please mail to:
COVENTRY HEALTH AND LIFE INSURANCE
PO Box 6495
Carol Stream IL 60197 -6495
COV001 PPFUGZ COV00123.RTP 1789/ 3988 CKP1R 144
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:•MYRTLE F. YORK
1043
KEVIN D YORK
14360 GREENBELT CT r7 zo 103ING
CARMEL -.IN 46033 8926 603
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Pay to the
Order of (✓J sr� !11�6L �t l7
KeyBank National Association Key Privilege
Carmel, Indiana 48033
-86 11i' Key
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For
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�074.0`O:L0.48� 'L46.03;20`067T81I' L;043
Date: 10/08/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
Bill To: MYRTLE F YORK ICD -9: 78609 78650
14360 GREENBELT CT
CARMEL, IN 46033
From: 14360 GREENBELT CT
To: HEART CENTER OF INDIANA
ADVANTRA FREEDOM
Patient: MYRTLE F YORK 801153564 -01
14360 GREENBELT CT Insurance
CARMEL, IN 46033 2
Patient No: 200801788
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
$387.50 $387.50 $0.00
CPT
Date Description Charges Credits
07/21/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00
07/21/2008 MILEAGE A0425 $37.50
08/19/2008 MEDICARE PAYMENT $237.50
09/09/2008 PAYMENT $150.00
10/07/2008 MEDICARE PAYMENT $150.40
10/07/2008 WRITE OFF- INSURANCE -0.40
10/08/2008 REFUND 150.00
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 10/08/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
N r
Bill To: MYRTLE F YORK ICD -9: 78609 78650
14360 GREENBELT CT
CARMEL, IN 46033
From: 14360 GREENBELT CT
To: HEART CENTER OF INDIANA
ADVANTRAFREEDOM
Patient: MYRTLE F YORK 801153564 -01
14360 GREENBELT CT Insurance
CARMEL, IN 46033 2
Patient No: 200801788
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
$387.50 $537.50 150.00
CPT
Date Description Charges Credits
07/21/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00
07/21/2008 MILEAGE A0425 $37.50
08/19/2008 MEDICARE PAYMENT $237.50
09/09/2008 PAYMENT $150.00
10/07/2008 MEDICARE PAYMENT $150.40
10/07/2008 WRITE OFF- INSURANCE -0.40
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
CITY OF CARMEL
4 R Nqta 4� bill t b e properly itemized Must show- kind of service, where performed, dates service rendered, by
w,rvnf, rates per aay, number of hours, rate per hour, number of units, price per unit, etc.
Payee
rqj r Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
rn.b S em 5
C-4 C
Total
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
VCS• tCHER NO. WARRANT NO.
ALLOWED 20
e Or IN SUM OF
156
ON ACCOUNT OF APPROPRIATION FOR
IA16
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
i
OCT 1 2008
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund