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Home My WebLink About164980 10/16/2008 F CITY OF CARMEL, INDIANA VENDOR: T362010 Page 1 of 1 ONE CIVIC SQUARE UNITED HEALTHCARE INS CO CHECK AMOUNT: $10.00 CARMEL, INDIANA 46032 PO BOX 30555 SALT LAKE CITY UT 84130 CHECK NUMBER: 164980 CHECK DATE: 10/16/2008 f �_PARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION '';102 5023990 10.00 OTHER EXPENSES r �r r N Date: 10/03/2008 r CARK8EL FIRE DEPARTMENT EMERGENCY MED8VCS 2 CIVIC SQUARE CARMEL. IN 46032' (317)571'2005 Fodora/ID# 356000972 KN T H iii i y Bill To: BARBARA EGGER ICD-9: 9596 9048 71945 E8859 7244 HARBOUR ISLE INDIANAPOLIS, IN 48240' From: 12195 N MERIDIAN ST To: ST. VINCENTS HOSPITAL CARMEL 1 UNITED HEALTH CARE/ 740800 Patient. BARBARA EGGER 7244 HARBOUR ISLE Insurance INDIANAPOLIS, IN 40240' Patient No: 200801709 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 Date Description CPT Charges CrLdit�s 07/I0/2008 BASIC LIFE SUPP-EMERGENCY A0429 $300.00 07/I0/2008 MILEAGE A0425 $12.50 08/I2/2008 COMMERCIAL INSURANCE PAYMENT $10.00 09/30/2008 COMMERCIAL INSURANCE PAYMENT $312.50 10/03/2008 REromo $-I0.00 APPROVED gY THE STATE BOARD Or ACCOUNTS FOR CITY OpcmnMsL.1sny Date: 10/03/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederallD# 356000972 Bill To: BARBARA J EGGER ICD -9: 9596 9048 71945 E8859 7244 HARBOUR ISLE INDIANAPOLIS, IN 46240 From: 12195 N MERIDIAN ST To: ST. VINCENTS HOSPITAL CARMEL UNITED HEALTH CARE 740800 Patient: BARBARA J EGGER 964941751 7244 HARBOUR ISLE Insurance INDIANAPOLIS, IN 46240- 2 Patient No: 200801709 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 $312.50 $322.50 -10.00 CPT Date Description Charges Credits 07/10/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00 07/10/2008 MILEAGE A0425 $12.50 08/12/2008 COMMERCIAL INSURANCE PAYMENT $10.00 09/30/2008 COMMERCIAL INSURANCE PAYMENT $312.50 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 PROVIDER INQUIRIES. CHECK REFERENCE '($00) '500 7044., Labe a. coDE K CK DATE U E CHE CUSTOMER SERVICE DEPARTMENT 18148493 09/25/08 FOR DISPUTES /APPEALS ONLY: v o P.O. BOX 8011 Mutuil- CHECK AMOUNT BLOCK NUMBER WAUSAU, WI.54402 -8011 288 ■$312.50 001271 SEND ORIGINAL BILLS TO: PAGE 1 OF 1 P.O. BOX 9191 34505 WEST TWELVE MILE RD. OSN: MM0801092501- 001271 FARMINGTN HLS, MI 48333 CLAIM NO. WC 440 616275 HOD INTERNAL BILL NO: 074813606 MSR: N0077377 CONTRACT NO: WC7- 181 053988 017 -92 CUST /EXTERNAL BILL NO: 26082460116400 DOCUMENT NO: 3K2410800230002 BR PROVIDER 00835600097200 PAYEE: CARMEL FIRE DEPARTMENT AMB PATIENT ACCT. 200801709 TAX ID: 35- 6000972 SSN: 314 -64 -9623 BILL PROV: CARMEL FIRE DEPARTMENT AMB DOI: 07/10/08 2 CIVIC SQUARE PATIENT: EGGER,BARBARA J CARMEL, IN 46032 7244 HARBOUR ISLE INDIANAPOLIS, IN 46240 EMPLOYER: MAX AND ERMA'S RESTAURANTS PROVIDER: CARMEL FIRE DEPARTMENT AMB LOCATION CODE: 000079 DATES OF SERVICE: 07/10/08- 07/10/08 AUDIT DATE: 09/24/08 DATE OF PROCEDURE MOD REVIEW PPO PREV CURR EXPL SERVICE CODE COE SERVICE DESCRIPTION UNITS CHARGES ALLOW ALLOW PAID PAID CODES 07/10/08 AMB01 AMBULANCE 1.00 312.50 312.50 N/A 0.00 312.50 TOTAL CHARGES: 312.50 TOTAL PREVIOUSLY PAID: 0.00 TOTAL CURRENT PAYABLE: 312.50 TOTAL WITHHOLDING: 0.00 R CEIVED SEP 3 0 2100E TOTAL AMOUNT PAID: 312.50 EXPLANATION CODE DESCRIPTIONS: Z849 TO OBTAIN ANSWERS TO MEDICAL BILL STATUS QUESTIONS, LEARN ABOUT OUR APPEAL PROCESS, OR CONTACT US FOR MEDICAL BILL RELATED INQUIRIES, PLEASE VISIT OUR WEBSITE: HTTPS:// PROVIDERSUPPORT .LMIG.COM /PROVSUPP /CONTROLLER ?CMD=LAUNCH. (Z849) Z850 MEDICAL BILLS FOR THIS CLAIM SHOULD BE SUBMITTED TO THE 'SEND BILLS TO' ADDRESS REFERENCED IN THE UPPER LEFT CORNER OF THE EOP. (Z850) NOTES IF YOU WOULD LIKE TO APPEAL A PAYMENT DECISION, PLEASE INCLUDE A COPY OF THE EOP, YOUR REASON FOR DISAGREEING WITH OUR DETERMINATION, AND ANY DOCUMENTATION YOU WOULD LIKE US TO REVIEW FOR RECONSIDERATION. FORWARD THIS INFORMATION TO THE 'APPEALS ONLY' ADDRESS LOCATED ON THE UPPERMOST LEFT CORNER OF THE EOP. (Z212) CAREFULLY DETACH CHECK BEFORE DEPOSITING RETAIN STATEMENT FOR YOUR RECORDS VERIFY THE A UTHENTI CITY OF THIS MULTI -TONE SECURITY D UMENZ CHE CK BAC KGROUND AREA ,CHANGES COLOR GRADUALLY FROM TOPTO BOTTOM. O.0'1271 TIT LIBERTY'MUTUAL WAUSAU` �,ibe CITI `DE P.O' BOX "-8011 ONE PENN S WAY 54402 -8011 1VIUtUaIA DE WAY VOID DI IP NOTSPR SENTED WITHIN 6.MONTHS "DATE OFCHECK OFFICE NO.E. -CODE PAYMENT ID.ENTIF.ICATION ":i CHECK /NUMBER CHECK DATE 949 288 'CLAIM WC h40= 616275 'HOD 18;1'48493 09/25/08 PAY► $312..50 x.:...:■::..*■.'.:."':. ■PAY THREE' HUNDRED ■TWELVE *DOLLARS'.FI'FTY *CENTS' PAY TO THe CA,RMEL FLR,E DE -P„ARTMENT” .AMB ORDER of 2, .0 I V I,C S.Q D A R E CARME'L _IN 46032 TWO SIGNATURES fEQUIRED IPIAOVER $150,000 NOT VALID IN EXCESS OF $312.50*` 11° 18 1 48 4 9 311' 1:0 3 1 100 2091: 386 2 194 511° �GI 'TFIFf1FS i:'- 1N2F Il!'lf`,IIM1l1C�IT.�LIAC�li LIGCI C(`71 /C�inl�iTCOnl1 /1'Ol:l -lk1 "TUC; Qntirlr sane =FZrt S =i.F .any.. t, per n..u.rvr_w.. ..v.u,.- .•r... e- =m Y6- 00128 *03 *000328 —PO- 08217 —HO 354 —FN 110 CFPA20 -070705 UNITED HEALTHCARE INSURANCE COMPANY �,l} s SPRINGFIELD SERVICE CENTER Unite Miealthe P 0 BOX 30555 A UnitedHeahh Group Company SALT LAKE CITY, UT 84130 -0555 PHONE: 1- 877 842 -3210 DATE: 08/04/08 TIN: 35- 6000972 NP I 1154325579 GROUP 0705019 GROUP NAME: MAX 9 ERMA'S RESTAURANTS, INC. CHECK NUMBER: VR 60031810 CHECK AMOUNT: SID.00 CARMEL FIRE DEPT AMBULANCE CARMEL FIRE DEPT AMBULANCE SV PROVIDER 2 CIVIC s4 EXPLANATION CARMEL IN 46032 OF BENEFITS PATIENT DETAIL PRODUCT HEM, ID PATIENT PAT PATIENT MEMBER CONTROL DATE PROVIDER NAME REL ACCOUNT NAME NUMBER RECEIVED OF SERVICE OPT /PPO A 964941751 BARBARA EGGER EE 200801709 BARBARA EGGER 01949090139 01 07128108 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, BARBARA 07/10/08 AMBULANCE 300.00 300.00 300.00 .00 W1 EGGER 07/10/08 AMBULANCE 12.50 12.50 80% 10.00 SUBTOTAL 312.50 312.50 300.00 10.00]( 302.50 TOTAL PAID TO PROVIDER $10.00 REMARKS (WI) THESE EXPENSES HAVE BEEN APPLIED TO THE PATIENT'S ANNUAL DEDUCTIBLE. THE PATIENT IS RESPONSIBLE FOR PAYING THE PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL ALL CHARGES THAT ARE APPLIED TO THE ANNUAL DEDUCTIBLE. PLEASE FORWARD THIS PAYMENT TO YOUR PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL. 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 AT 1- 800 842 -1109, OPTION 3. PAYMENT OF BENEFITS HAS BEEN MADE IN ACCORDANCE WITH THE TERMS OF THE MANAGED CARE SYSTEM. RECEIVED AUG 1 2 2008 Detach Check Detach Check 51 44 Fleet National Bank °.SPRI N UNITED- HEALTHCARE INSURANCE•COMPANY 150 Windsor Street Hartford, CT 06120 V R 8 00..3,1 `3 1.` 0 GFIELD `SERVICE .CENTER P'OBOX 30555. SALT LAKE :CITY, UT 84130- 0555 DATE :-'08/04]08 ;:RHONE s 1 8.77 =.842 -32.10 Y6= 00128 000328 —PD 08217 —HO- 354 —FN f10 PLEASE PRESENT PROMPTLY FOR PAYMENT CONTRACT. :705019 PAY: *ic *TEN, &'00 /1.00,: DOLLARS,,:*:**********;*****************:***********.***** a PAY CARMEL,FIRE::.DEPT AMBULANCE SVC CARMEL F:IREDEPT AMBULANCE SV TO THE, 2 CIVIC so I ORDER -OF CARMEL IN 46032 AUTHORIZED SIGNATURE i' II unl6hl Illliilm 1 ril mllnii dluu uul 1 it II 6illuillludllnliluulilu Idoduulllludirilll >1 dilitdumnhl�ullihllllrinllnll ti ndll r Idhddlluuluihidnlud m6 116dndulf uulr(uunninl dinlrlll 6dmnlliiddidl6duliihrlu6JnlnlaliJldtilulnhrlulnLdiilrtlull lrrdlrurl6illnulL Ibu II I w m6u II nl6ulllriillld111 u "8003 1:8 L00 i:0 L L,90044'St: 2 2 4 000 9 >L0 LII' 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. I Paye e Ut 7,� 4eoL ea_Jq/I,� Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) b a- L CJ Total /D 00 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 *x Clerk- Treasurer VOUCHER NO. WARRANT NO. ALLOWED 20 (�U'UPG� ��'CS w IN SUM OF /6. C-) ON ACCOUNT OF APPROPRIATION FOR Board Members PO# or INVOICE NO. ACCT #!TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or 071- 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 OCT 13 2008 20 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund