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Home My WebLink About156861 02/21/2008 CITY OF CARMEL, INDIANA VENDOR: T0002825 Page 1 of 1 ONE CIVIC SQUARE UNITED HEALTHCARE CARMEL, INDIANA 46032 PO BOX 740803 CHECK AMOUNT: $254.40 ATLANTA GA 30374 -0803 CHECK NUMBER: 156861 CHECK DATE: 2/21/2008 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 254.40 OTHER EXPENSES ;413 9 0 CM C-2 AMERICAN FAMILY INSURANCE GROUP- MADISON. WISCONSIN OFFICE 5 4 WM ISAL WIM ONSIN CLAIM NO. 00-541 -i433845 POLICY NO. 06675928-05 DATE 01/11/2008 F I,--,( )TI i E OR L) F.R CARN/IEL FIRE DEPARTMENT PAYMENT NUNIBC12 OF 0054117703 INSURED WYCOFEJEFFREY C A'wl( )L I NNT 15.00 PAY THREE. HUNDRED EIGHTEEN AND 00/100 DOLLAR z`� CHIEF FINAN( IAL OFf ICERi TREAAWER MAIL TO: CARNIEL FIRE DEPARTMENT EMERGENCYNIED SERVICES e 2 CIVIC SQUARE CARAMEL IN 400' PRESIDENT u 005 b b77 1 0 7 5 :1 6031° Eb 238 8 5 5 7 111 1 PLEASE TEAR AT RED DOTTED LINE A IN PAYNIENT OF i'viedical Expense Claim o['09/25/200 Service Date: 09/25/2007 for WYCOFF. REBECCA ID PERIL, AMOUNT CLAINI TIN 01 04 S I S. 00 00-541-543845 1-56000972 W6- 00633 *03 *001668 -PO- 07330 -60- 416 -CN 110 CFPA10 070123 UNITED HEALTHCARE INSURANCE COMPANY SPRINGFIELD SERVICE CENTER United Healthcare PO BOX 740800 ATLANTA, GA 30374 -0800 �J AUnrcedHealch Group Company PHONE: 1- 877 -842 -3210 DATE 11126/07 TIN: 35- 6000972 GROUP 0706694 GROUP NAME: CONSECO SERVICES LLC CHECK NUMBER: UT 30510590 .0 iEG i4l UJ I 5254.40 PROVIDER CARMEL FIRE DEPT AMBULANCE SVC EXPLANAT CARMEL FIRE DEPT AMBULANCE SV 2 CIVIC SQ �ry CARMEL IN 46032 OF BENEFITS PATIENT DETAIL PRODUCT MEM. 1D PATIENT IPAT, PATIENT MEMBER CONTROL DATE PROVIDER NAME REL ACCOUNT NAME NUMBER RECEIVED OF SERVICE CHOYC+ A 9606/1325 REBECCA WYCOFF E 200702/51 REBECCA WYCOFF 01758846985 -01 11/19/0,' CARMEL FIRE DEPT AMBU SERVICE DETAIL PATIENT DATES OF DESCRIPTION AMOUNT NOT PROV ADJ AMOUNT DEDUCT/ PLAN PAID TO RMK PATIENT NAME SERVICE OF SERVICE CHARGED COVERED DISCOUNT ALLOWED COPAY COV PROVIDER CD RESP. REBECCA 09/25/07 AMBULANCE 300.00 300.00 80% 240.00 NO WYCOFF 09/25/07 AMBULANCE 18.00 18.00 80% 14.40 NO SUBTOTAL 318.00 318.00 254.40# ND 63.60 TOTAL PAID TO PROVIDER 5254.40 REMARKS (ND) A NON NETWORK HEALTH CARE PROVIDER OR FACILITY PROVIDED THESE SERVICES. YOUR CLAIM HAS BEEN PAID BASED ON YOUR BENEFIT PLAN, WHICH USES BENCHMARKS ESTABLISHED BY THE FEDERAL GOVERNMENT, INCLUDING RATES AND METHODOLOGIES USED BY THE MEDICARE PROGRAM. YOU ARE RESPONSIBLE FOR PAYING THE AMOUNT IN THE NOT COVERED COLUMN. THE NOT COVERED AMOUNT DOES NOT APPLY TO YOUR OUT OF POCKET MAXIMUM. NPI 1154325579 UNITEDHEALTHCARE IS IMPROVING SERVICE TO YOU BY ADOPTING ELECTRONIC PAYMENTS STATEMENTS (EPS) AS A STANDARD WAY TO PAY CLAIMS. EPS WILL DRAMATICALLY REDUCE THE TIME AND EFFORT YOUR ORGANIZATION SPENDS ON ADMINISTERING PAPER CHECKS AND EXPLANATION OF BENEFITS. GET A HEAD START AND ENROLL TODAY BY SELECTING THE ELECTRONIC PAYMENTS STATEMENTS LINK FOUND ON THE HOME PAGE OF WWW.UNITEDHEALTHCAREONLINE.COM OR CONTACT US AT 1- 866 -UHC -FAST (1- 866 842 3278), OPTION 5. FOR MORE INFORMATION ABOUT OUR FREE OR LOW COST SOLUTIONS FOR SUBMITTING CLAIMS ELECTRONICALLY TO UNITEDHEALTHCARE AND OTHER PAYERS, PLEASE CONTACT US TOLL FREE 1- 800 842 -1109, OPTION 3. PAYMENT OF BENEFITS HAS BEEN MADE IN ACCORDANCE WITH THE TERMS OF THE MANAGED CARE SYSTEM. Detach Check Detach Check 50 -937 The Chase Manhattan Bank 213 UNITED HEALTHCARE INSURANCE COMPANY Syracuse, NY 305 SPRINGFIELD SERVICE CENTER PO:BOX:740800 ATLANTA ,GA: 30374 -0800 DATE: 11. /26/07 PHONE.: .1= 877 -842 -3210 W6- 00633 001668 -PO- 07330 -60- 416 —CH 110 PLEASE PRESENT PROMPTLY FOR PAYMENT :CONTRACT: 708694 PAY 2.54 .4 0 *TWO' >HUNDRED FIFTY FOUR 40/100 DOLLARS************************ *K P AY TO THE CARMEL FIRE ,DEPT AMBULANCE SVC CARMEL ..FIRE DEPT AMBULANCE SV ORDER OF 2 CIVIC SQ CARMEL IN 46032 AUTHORIZED SIGNATURE I i l u 611 n 6 d u l i d i d I i I n I u 6 i l u l u 6 i l i d n I u l u l u I n I n I u l u l i i 6 d i i l u l u 6 d i i 6 d u I n I n I i i L d n l l i l n l n l n 6 d u l n l n l n l n l n l u l u l u 6 d u l u l u l u l u l n l n l u l u l u l n 616 d u l u h d l d u I n I u L d u 6 d u l u l u l u I I l u d I n u 16 u d I n u I l u n 16 u d I u u I h 1 i d L w i 6 J I d I I d i I I J i I I n 1611 i I n n I I l i i l u 6 i l u u I d J u i I I I d I I J i l u d l i d 1611 h 61110 i i i l l l I'° 30 S 10 S 9 01I` t :0 2 3D 9 3 9 k BPI D 0 60 20 Date: 02/12/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: REBECCA J WYCOFF ICD -9: 9569 78702 71947 E8130 10822 GLENAYR DR CAMBY, IN 46113 From: 111TH PENNSYLVANIA To: ST. VINCENT CARMEL UNITED HEALTH CARE/ 740800 Patient: REBECCA J WYCOFF 960611325 10822 GLENAYR DR Insurance CAMBY, IN 46113- 2 Patient No: 200702151 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 $318.00 $318.00 $0.00 CPT Date Description Charges Credits 09/25/2007 BASIC LIFE SUPP- EMERGENCY A0429 $300.00 09/25/2007 MILEAGE A0425 $18.00 11/30/2007 COMMERCIAL INSURANCE PAYMENT $254.40 01/18/2008 COMMERCIAL INSURANCE PAYMENT $318.00 02/12/2008 REFUND 254.40 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 02/12/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal ID# 356000972 a �0 a Bill To: REBECCA J WYCOFF ICD -9: 9569 78702 71947 E8130 10822 GLENAYR DR CAMBY, IN 46113 From: 111TH PENNSYLVANIA To: ST. VINCENT CARMEL UNITED HEALTH CARE/ 740800 Patient: REBECCA J WYCOFF 960611325 10822 GLENAYR DR Insurance CAMBY, IN 46113- 2 Patient No: 200702151 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 $318.00 $572.40 254.40 CPT Date Description Charges Credits 09/25/2007 BASIC LIFE SUPP— EMERGENCY A0429 $300.00 09/25/2007 MILEAGE A0425 $18.00 11/30/2007 COMMERCIAL INSURANCE PAYMENT $254.40 01/18/2008 COMMERCIAL INSURANCE PAYMENT $318.00 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 ;Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995) CITY OF CARMEL An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. Payee n 7✓ �8,, Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) IZZY Total I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance with IC 5- 11- 10 -1.6. 20 Clerk- Treasurer VOUCHER NO. WARRANT NO. ALLOWED 20 I N S U M O F$ 1 C;,�5 yo 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 2a0ZtZ> Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund