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Home My WebLink About158334 04/15/2008 CITY OF CARMEL, INDIANA VENDOR: T0002820 Page 1 of I ONE CIVIC SQUARE CIGNA HEALTHCARE INC CARMEL, INDIANA 46032 PO BOX 182223 CHECK AMOUNT: $264.00 �y row s o CHATTANOOGATN 37422 CHECK NUMBER: 158334 CHECK DATE: 4/15/2008 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 264.00 REFUND K ,A Date: 04/07/2008 CARMEL FIRE DEPARTMENT EMERGENCY MEDSVCS 2 CIVIC SQUARE CARMEL,.IN 46032- (317)571 -2605 FederaiiD# 356000972 o� Bill To: ANGELA WORZALA 1CD -9: V714 V222 E8130 3823 CONSTITUTION DR CARMEL, IN 46032 From: 10679 N MICHIGAN RD To: CLARIAN NORTH CIGNA 5200 Patient: ANGELA WORZALA U2058062801 3823 CONSTITUTION DR Insurance CARMEL, IN 46032- 2 Patient No: 200702246 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 $330.00 $594.00 264.00 CPT Date Description Charges Credits 10/06/2007 BASIC LIFE SUPP EMERGENCY A0429 $300.00 10/06/2007 MILEAGE A0425 $30.00 12/18/2007 COMMERCIAL INSURANCE PAYMENT $264.00 12/21/2007 COMMERCIAL INSURANCE PAYMENT $330.00 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 04/07/2008 CARMEL FIRE DEPARTMENT r EMERGENCY MED SVCS r 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: ANGELA WORZALA ICD -9: V714 V222 E8130 3823 CONSTITUTION DR CARMEL, IN 46032 From: 10679 N MICHIGAN RD To: CLARIAN NORTH 1 CIGNA 5200 Patient: ANGELA WORZALA U2058062801 3823 CONSTITUTION DR insurance CARMEL, IN 46032- 2 Patient No: 200702246 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 $330.00 $330.00 $0.00 CPT Date Description Charges Credits 10/06/2007 DASTC LIFE SUPP- EMERGENCY A0429 $300.00 10/06/2007 MILEAGE A0425 $30.00 12/18/2007 COMMERCIAL INSURANCE PAYMENT $264.00 12/21/2007 COMMERCIAL NSURANCE -PAYMENT $330.00 04/07/2008 REFUND 264.00 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 ooeso� CON NECT]CUTG ENE RAl., LIFE INS URANCLCOMPANI' BOURBONNAIS C]_AIM OFT 1'. 0. BOX 1.52223 CHA'Ti'ANOOGA TN 37922 -722:3 CONNE?CTIC;UTGENERAL .1,111? INSU]ItANC ECOMPANV CIGNA Health.Care AS AGENT FOR LAUTH GROUP. INC. Provider Nurmber, 356000972 0000 Dace through which ciainis %sere processed: 12/11/2007 Itital1 lilt I lilt III tItGlttlalIItltlt111111JI lilt lilt 11is111 Pavluc CARMEL FIRE DEPT 465 2 CARMEL CIVIC SO CARMEL IN 46032 -2584 How to Contact Us Ttall to the return ac7dresY in u[rt�er R E rr trtt: corner of tt =is lrage. Phone: (8(10) 244-6224 Provider E'xplaaaatation o f Medical Payment Understanding this Bene Statement This page provides a summary of the paymen Ls rnadte this period. The accompanying pages give more detail on the claims we processed for this period. Please review both fhe front and back of each pane to see how the benefit amounts in the Provider Explanation of Medical Pay l Report were determined. In the event a claim is den.ied...... Rights o (Review and Appeal For Physiciau or Health Care Provider If YOU have questions or disagree with the 1 ayment identified on dvs Lxplaria tic) n of Medical Payment Report, you may asl; to have it reviewed. Itvou have contrachtal agreement with CIGNA FlealthCare,please refer to the procedural guiclelinesassociated wiLh vour CIGNA liealLhCare contracL, or call Our office for assistance. Rights ofReviety and Appeal For Employee Call Memher Services at the toll free number on this Explanation of Benefits (E'013) or your 11) card if you have questions regardi11g this EOB. lfycau're not satisfied with this coverar =e decisio you can star the Appeal process by srtbmitting a written request_ to the address listed in your plan materials within. I ec days of reijlt of this E013 (unless a longer tune is permitted by your plan). Send a copy of this LOB along with any relevant additional information (e,s beneflt documents, chniLll records) which helps to demonstrate that your claim is covered under the plan. Contact Member Services if you need further instructions on how and where to send your request for review, Be sure to include your I Name, 2) Question Location/Group Nu.mher, 3) Employee /Patient 11) number, 4) Name of the patient and relationship, and 5) "Attention: f ppeais Unit' on all supporting= documents. You are entitled to receive free upon request access to, and copies o�, ail documents, records and other information relevant to your claim for benefits. You will he notified of the final decision in at timely manner, as described in vour plan materials. if your plan is governc -'d by ERNA, you also have the right to bring legal action under section 5012 f a) of ERISA following our review. Parnent S Check Number. 0 Check Amount: $264.00 Check Date: 12/11/2007 G2434C 06-28 -2006 PROCLAIM Medicai Provider EOP Detach on Perforation Below Please Cash Promptly CONNECT) UTGENE1tXL'11FE 1NSUItANC E CE)3► PANX A$ AG€:N1 7 F0R m. DD87I26Q56 LAUTH(;R INC 50- cr37r213' 7 �r DATE Provta tt er 91. �3�i� Papl 12 /Zll2DD7 :..356DDD9.r'v ODDO TWO HUNDRED SIXTY :FOUR DOLLARS AND OO:GENTS 1'av "CARMEL TIRE DEPT I�c�ila[5 I 264. 00 CARMEt Ik :Order 46 D32 2584 Void If tVotCashed Within 1$0 Days of J PMORCiRN CHASE 13ANK, N A: "z SYRACUSE: NEW YORK 332:6004 THE[7RIGINALWOCUMENT'HAS A REf°LECLEVE WATERMARK' c ON THE BACK HOLD'AT AN 'ANGLE TO VIEW ��G2434G�OB•28.200c3 :Medical :P«swtdet _OP 11 26056 ?III 100 2 130 4 3 791. E,O to18�et 95? I'd g Provider Explanatioti o fMedical Pays tent Report CIGNA H-14l,( are Provider NuH I)CF j Provider Name j Date through which claims were processed ll 1 1 1 IS IS NO T A 1311.,E Page 356000972 0000 CARMEL FIRE DEPT" I 12/07/2007 Retain for Your Records I Ad usted ERG% DRC DRG/ i Procedure Adjusted Billed I t Line Procedure Date Procedure. 1 rocedure Cod per Diem Per Diem I Allowed No[ Covered/ Deduct /CoPay Coinsurance IJRG /I er Diem I Per Diem See I Code I lntount ''Amount Disr�unt lmotmt Amount Amount I Bertelit PI n Benefit I Hole Code. Amount 1 Amount j PATIENT NAME: ANGELA WORZALA PATIENT#: 200702246 OPERATION LOCATION /GROUP# 32683 9- 3326004 RECEIVE DATE: !2/03/2007 PROCESS DATE: 12/07 MEMBER NAME: ANGELA WORZALA SUBSCRIBER U26S80628 REF 4650733899430 CHECK 00871260567 i 1 l �l 10062007 A0429 300.00 300.00 60.00 0.00 0.00 240.00 l 1 2 j 10062007 A0425 30.00 30.00 6.00 0.00 0.00 24.00 TOTAL 330.00 330.00 264.00 BALANCE. 566.00 WHY WAIT FOR THE MAIL? VIEW ELIGIBILITY, BENEFITS OR CLAIM DETAILS ONLINE ANYTIME AT IITTP: /WWW,CIGHA.COK /HEALTH /PROVIDER/ j PAYMENT OF 5264.00 TO CARMEL FIRE DEPT Q HN7 LIA �d l 1' i I I I I i l j 1 I I j r l 1 G2436D 03 -23 -2005 Proclaim Provider EOP Summary b 0 E Z b E 0 5 0 4!£ r VOID IF NOT PRESENTED WITHIN 6 MONTHS AFTER DATE OF ISSUE P oky I nsured ate Issued Area C ode D raft -'s89 47835619 005 MILLER, BENJAMIN 12117/2007 802 Number 454555303 412 Claim Claimant Date of Loss State Code Office Issued At PAC 071436444 WORZALA, ANGELA 101 6!2007 IN IN- INDYC -GRP- Dollars S *330,00 DAY THREE HUNDRED THIRTY AND 00 /100 in Pa ment Of AMBULANCE PATIENT 200702246 coos 13PCL Payable through National City Bank ASHLAND, OHIO 1- 877 448 -0544 Progressive Southeastern Insurance Co=any p ay CARMEL FIRE DEPARTMENT ONLY To 2 CIVIC SQUARE CARMEL IN 46032 f BY �A AtJTH =E SIGNATURE �i° 4 5 4 5 5 5 30 iii° 004 b 2D 38 5�0 7 70 �8 20i3° 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 U Purchase Order No. Terms Q Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 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 IN SUM OF s c2 �o�Z ON ACCOUNT OF APPROPRIATION FOR 4 awe 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 200 �A S naturo� Title Cost distribution ledger classification if claim paid motor vehicle highway fund