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HomeMy WebLinkAbout162848 08/20/2008 CITY OF CARMEL, INDIANA VENDOR: T361695 Page 1 of 1 ONE CIVIC SQUARE MARY LEISURE 0 CHECK AMOUNT: $73.75 1. CARMEL, INDIANA 46032 1040E 108TH ST INDPLS IN 46280 CHECK NUMBER: 162848 CHECK DATE: 8/20/2008 D EPARTMENT ACCOUNT PO NUMBER INVOICE NU MBER AMOUNT DESCRIPTION 102 J 5023990 73.75 OTHER EXPENSES i i CI 'T' ARMEL JAMES BRAINARD, MAYOR August 18, 2008 Ms. Mary Leisure 1040 E. 108` St. Indianapolis, IN 46280 RE: INVOICE #200800697/ D.O.S. 03/09/2008 Dear Ms. Leisure: Enclosed you will find a reimbursement check in the amount of $73.75. On May 7, 2008, we received a check from Physicians Mutual for your ambulance bill on March 9, 2008 in the amount of $73.75. On June 27, 2008 we received a check from Aetna for the same amount for the same transport. Since you have 2 supplemental insurances, I am issuing you a refund of $73.75. If you have any questions, please feel free to contact me at (317) 571 -2605. Sincerely, Bec*SL nnan Ambulance Billing /Accounts Receivable CARMEI, FIRE. DEEARTMENT STEVEN A. CouTs HEADQUARTERS Two CIVIC SQUARE, CARME.L, IN 46032 OEiicE 317.571.2600 FAx 317.571.2615 Date: 08/18/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: MARY B LEISURE ICD -9: 78609 7867 7862 7823 1040 EAST 108TH STREET INDIANAPOLIS, IN 46280 From: 1040E 108TH ST To: ST. VINCENT CARMEL 1 MEDICARE PART B Patient: MARY B LEISURE 307121728A 1040 EAST 108TH STREET Insurance INDIANAPOLIS, IN 46280 2 UNITED HEALTH INS/30555 307121728 Patient No: 200800697 PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $368.75 $442.50 -73.75 CPT Date Description Charges Credits 03/09/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00 03/09/2008 MILEAGE A0425 $18.75 04/22/2008 MEDICARE PAYMENT $295.00 05/07/2008 COMMERCIAL INSURANCE PAYMENT $73.75 06/27/2008 COMMERCIAL INSURANCE PAYMENT $73.75 07/01/2008 REFUND -73.75 08/18/2008 REFUND $73.75 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 08/18/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederallD# 356000972 t; Bill To: MARY B LEISURE ICD -9: 78609 7867 7862 7823 1040 EAST 108TH STREET INDIANAPOLIS, IN 46280 From: 1040 E 108TH ST To: ST. VINCENT CARMEL 1 MEDICARE PART B Patient: MARY B LEISURE 307121728A 1040 EAST 108TH STREET Insurance INDIANAPOLIS, IN 46280 2 UNITED HEALTH INS/30555 Patient No: 200800697 307121728 PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $368.75 $368.75 $0.00 CPT Date Description Charges Credits 03/09/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00 03/09/2008 MILEAGE A0425 $18.75 04/22/2008 MEDICARE PAYMENT $295.00 05/07/2008 COMMERCIAL INSURANCE PAYMENT $73.75 06/27/2008 COMMERCIAL INSURANCE PAYMENT $73.75 07/01/2008 REFUND -73.75 08/18/2008 REFUND $73.75 08/18/2008 REFUND -73.75 i APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 N1 N-I I-S IN- P:1 3 OI i (Phis portion intentionally left blank.) _e 0 RECEIVED MNf 0 7 2008 N226 -1106 PHYSICIANS MUTUAL_ INSURANCE" COMPANY '�TE131Z: =ASIiA !68131 PAYABLETHROUGH. FIRST NATIONAL BANK OF OhL4_HA 10.19 OrAAHAh N'EBRASg A6310 FRET`- _IONTNA- n(?NALB4NK TCO 1 X923 �I l I Ili t, i i 1 I I :FREMUNf N'EPFL4SK.� G30 5 �I w,y I j'. I I i i i ii 0771)1 CLAIM:: "DATE DRAFT NO. ANC 6NT 04/28/08 018412172 -1 $1. 1. 2; PAY TO TI IE ORDER OF �y,• G j. i m1 n �I u i n r CARMEL FIRS DE PAR r••:,ry 2 CARMEL CIVIC S CARMELIN 46032 I1a❑ L84 L 2 L7 211' 1 /04900048 09 LO L887 11' Physicians Physicians Mutual Insurance Company Mutual Physicians Life Insurance Company' April 28. 2008 Tax Ill No. 356000972 Draft. No. 018412172 Explanation of Benefits Ie Ie PNII 1led�c ii a I\Ied� care d�care d�ca� e C Deduct Paid P I. uie Patient .1cct: N I .>lt�ent 1\amc Ser. C,.,Lum 10. I3dledpp� o .ea l44 1 No. EOi1'1I3 �.'onfrol No Datef I;n th Date(5) llescripton of Sci ice Per for P_i os ides 001 -07 200800697 IMARY 13 LFISURF 0109/2008 QID8597 -0 368.75 368.75 0.00 295.00 73.75 1108095058310 05,27/14 03/09/2008 Part 13 kledical 13enelit C'ARNIEL FIRE DEPARTMENT 002 -08 200800694 \1 JEANNENE FINLEY 03i09i2008 N:QF3975 -0 387.50 387.50 0.00 310.00 77.50 1108095058290 09:17/37 03/09/2008 Part 13 Medical 13enel C'ARMEL FIRE DEPART>\fEN "f 1 otal lniowit. $1-51 .25 Re4stilt Codes RS Claims may now he sent to us electronically via our clearinghouse. Emdeon. using our I'aeor 11) number 47027. NO "1'1:: Do not send Medicare supplement claims as they are received directly from the Medicare carriers. RP All adjustment claims may not be received electronically. If there is no indication on the Medicare statement ot'the claim beingTorrearded to us. please send paper copies of all monetary adjustments For our consideration. RECEIVID MAY 7 ZUU6 r r to 4227-5 llA P.O. BOX 981 107 E XPLAN,4 TION ®F BENEFITS ��t��.p EL PASO, TX 79998 -1107 USA Please Retain for Future Rererencr 008213 J280DUA2 023034 CITY OF CARMEL FIRE DEPT. PIN: 000574510( Check No: 08325/04959040 Page 2 of 2 Date Printed 04/29/2008 CITY OF CARMEL FIRE DEPT. Tax Identification Number: XXXXXXXX0972 2 CIVIC SO Check Number. 08325/049590404 CARMEL IN 46032 -2584 Check Amount: $73:75 Notes: The benefits listed below reflect your portion of this payment. Address, telephone number, e-mail and /or N PI numbers can be added or updated online. Medical: visit https: //www.aetna.com /provweb Dentists: Log in to the www.aetnadental.com secure site and select Update Personal Information. Sign -up today for free electronic remittance advice and electronic funds transfer (ERA/EFT). Visit http: //www.aetna.com/ provider /eraeft_enrollment.html to learn more and to register. Patient Name: AKroanY B LEISURE (self) Claim ID: EMAACJH9900 Recd: 04/22/08 Member ID: W102839647 Patient Account: 200800697 Member: MARY B LEISURE DIAG: 78609 7867 7862 Group Name: BP CORPORATION NORTH AMERICA INC. Group Number: 724775 -15 -001 CM CANZ`0 Product Traditional Choice@ Network ID: 00000 Aetna Life Insurance Compan SERVICE PL SERVICE NUM. SUBMITTED. ALLOWABLE: COPAY NOT SEE::,.. DEDUCTIBLE, CO PATIENT :;I :_:,PAYABLE::..:. DATES CODE Svcs CHARGES :AMOUNT AMOUNT PAYABLE .REMARKS INSURANCE`RESP :AMOUNT 03108108 41 A0427RH 1 350.00 350.00 03108108 4 A0425RH 3 18.75 18175 TOTALS 368.75 366.75 Less Amount Paid by Other Health Plan $295.00 ISSUED 'AMT. $73.75 For Questions Regarding This Claim P.O. BOX 14586.LEXINGTON, KY 40512 Total Patient Respon "slbility: $0 00 CALL (888) 632 3862 FOR ASSISTANCE Claim Payment $73 75 Note: All Inquides should reference the ID numberabove for prompt response. Total P to: CITY O F CARMEL FIRE DEPT $73 Protecting the privacy of member health information is a top priority at Aetna. When contacting us about this statement or for help with other questions, please be prepared to provide your Aetna provider number, tax identification number (TIN), or Social Security number (SSN), in addition to the Aetna member's ID number. L4a;GEI�IED JUN 2 7 20�� P O. BOX 981107 fiL/a�M <PA YMENT EL PASO, A50, TX 19998 -1107 Please Refain for Future Reference 008213 J280DUN2 023032 CITY OF CARMEL FIRE DEPT. PIN: 0005745100 CITY OF CARMEL FIRE DEPT. 2 CIVIC SQ CARMEL IN 46032 -2584 meN t RECEIVES JUG! 2 7 2008 a Aetna Llfe Insurance Compamy a an''Afillleted ID No X XX0972 Check No: 049590404 ti` Company as "Agent for Spedhed Payers) Seq NO :000010630 AOCt 38208325 r r r 3 e P O BOX 881107 a E� TX.79998 1107 N t.+ c? USA z* �c ,y I�III4 A t sez 20 9r� w 'c�1. 1 "t c�{ •�.G Sr Yft m �{y III I M.v,. ,'W r 3 311 'v c 'e°.: F s Yv ;a {a?� e I :s t I pp 3� W ?,'2 t 4 r ,ra r"'' z PAYER BP�CORPORTION NORTH AMERICAINC r 'e O n PAYS- {Se ✓enfyrl +hree Dollars and 75/100 Nppl r ;._v.« �C culli��I�IIGhr .`ie IIIIIIi N" INW "Ilil N �Y NOID AER �1E17 TO -THE EPTARTMENT, ORbER ®F r` s� :2 CIVICSQ tua Vdm ro9lul)rou I!'hllnVlz x d I iri' $7375 6AIRMEL >IN 60.32 2584 t� Cltlbenk N A New Castle DE 19720 �X 1aa ovµ `m i i1 w1 a g x lee taxi r ax jx e y d P� I H t i ¢fi 2 zzz m Ilil II r k .II 4 D49 59 col- 38 0.3 .LtL00.2`09 Date: 08/18/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: MARY B LEISURE ICD -9: 78609 7867 7862 7823 1040 EAST 108TH STREET INDIANAPOLIS, IN 46280 From: 1040E 108TH ST To: ST. VINCENT CARMEL I MEDICARE PART B Patient: MARY B LEISURE 307121728A 1040 EAST 108TH STREET Insurance INDIANAPOLIS, IN 46280 2 UNITED HEALTH INS/30555 307121728 Patient No: 200800697 PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $368.75 $442.50 -73.75 CPT Date Description Charges Credits 03/09/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00 03/09/2008 MILEAGE A0425 $18.75 04/22/2008 MEDICARE PAYMENT $295.00 05/07/2008 COMMERCIAL INSURANCE PAYMENT $73.75 06/27/2008 COMMERCIAL INSURANCE PAYMENT $73.75 07/01/2008 REFUND -73.75 08/18/2008 REFUND $73.75 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 08/18/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederallD# 356000972 ,w Bill To: MARY B LEISURE ICD -9: 78609 7867 7862 7823 1040 EAST 108TH STREET INDIANAPOLIS, IN 46280 From: 1040E 108TH ST To: ST. VINCENT CARMEL 1 MEDICARE PART B Patient: MARY B LEISURE 307121728A 1040 EAST 108TH STREET Insurance INDIANAPOLIS, IN 46280 2 UNITED HEALTH INS/30555 Patient No: 200800697 307121728 PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $368.75 $368.75 $0.00 CPT Date Description Charges Credits 03/09/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00 03/09/2008 MILEAGE A0425 $18.75 04/22/2008 MEDICARE PAYMENT $295.00 05/07/2008 COMMERCIAL INSURANCE PAYMENT $73.75 06/27/2008 COMMERCIAL INSURANCE PAYMENT $73.75 07/01/2008 REFUND -73.75 08/18/2008 REFUND $73.75 08/18/2008 REFUND -73.75 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 I'A 1 3SON- Pfl'�d 3 of ('T'his portion intentionally left RECEIVE WlAt 0 7 2008 N226 -1106 PHYSICIANS MUTUAL INSURANCE COMPANY OA147IA NEBRASKA .68131 PAYABLE THROUGH FIRST NATIONAL BANK OF 01,9AHA 1049 UMAE3.9:' NEBRAb'f a. GS 10 1�A4ONT NATIONALBANK CTRUST, CO I FREMC)NT 10EFR.4Sii.� 650 a r; y I 4 07700 w D 1TE DRAFT NCB.. aN 04/28/0K 0184I2172 -I 7 P TG THE ORDE12 0 1 CARMEL FIRE DEPARTMENT 2 CARMEL CIVIC SCZ CARMEL IN 46032 II L84 1 2 :7 2Il II: b049000L,8 09 b0 b887 II® Physicians Physicians Mutual Insurance Company Mutual" Physicians Life Insurance Company April 28. 2008 Tax ID No. 3 ?6000972 Draft. No. 018412172 Explanation of Benefits Nledicaie �'Ied� care Nlechc�ire �Iedicare PNIIC' Line Patient lccf No E Pat�etit l\ume Service (:'!aim I`o. Billed 1pploied Deduct Paid: Paid No OAIB C'o�itroi No Date of Birth; Dates) Dek ipfion of Sei i ice Perfornwi I'ro� idea 001 -07 2008 00697 NI_aRY B LEISURE 03,.W2008 VQD8597 -0 368.75 368.75 0.00 295.00 73.75 110809 -5058310 05,27/14 03/09/2008 Part B N'[edical 13ene.lit C'ARNIEL FIRE DEPARTMENT 002 -08 200800694 1\1 JEANNENE FINLEY 03/09/2008 VQF3975 -0 387.50 387.50 0.00 310.00 77.50 1108095058290 09!17/37 03!09/2008 Part B N-ledical Benefit CARNIEL FIRI: DEPARTMENT Total .lmowit I`snclosed $151.Z� Reason Codes RS Claims may now be sent to us electronically via our clearinghouse. Emdeon. using our Pa }'or ID number =47027. NOTE: Do not send Ndedicare supplement claims as they are received directly from the Nledicare carriers. RP All adjustment claims may not be received electronicall Il'there is no indication on the kledicare statement or the claim being forwarded to us. please send paper copies of all monetary adiustments for our consideration. RECEIVED MAY 7 ZUU8 fJ r X227 -5 X Ae-t n a P O E XPLANATION OF BENEFITS EL PASO, TX 79998 -1107 USA Please Retain for Future Reference 008213 J280DUA2 023034 CITY OF CARMEL FIRE DEPT. PIN: 000574510( Check No: 08325/04959040 Page 2 of 2 Date Printed 04/29/2008 CITY OF CARMEL FIRE DEPT. Tax Identification Number: XXXXXXXX0972 2 CIVIC SQ Check Number:': 08325/049590404 CARMEL IN 46032 -2584 Check Amount: $73:75 Notes: The benefits listed belowreflect yourportion of this payment. Address, telephone number, e-mail and /or N PI numbers can be added or updated online. Medical: visit https: /www.aetna.com /provweb Dentists: Log in to the www.aetnadental.com secure site and select Update Personal Information. Sign -up today for free electronic remittance advice and electronic funds transfer (ERA/EFT). Visit http provider /eraeit_enrollm en to learn more and to register. Claim ID: EMAACJH9900 Recd: 04/22/08 Member ID: W102839647 Patient Account: 200800697 Member: MARY B LEISURE DIAG: 78609 7867 7862 Group Name: BP CORPORATION NORTH AMERICA INC. Group Number: 724775 -15 -001 CM CANZ`0 Produce. Traditional Choice@ Network ID: 00000 Aetna Life Insurance Compan SERVICE PL SERVICE NUM. SUBMITTED ALLOWABLE:: COPAY NOT SEE DEDUCTIBLE' CO PATIENT ;PAYABLE DATES CODE SVCS :CHARGES AMOUNT AMOUNT PAYABLEREMARKS':. INSURANCE '..RESP AMOUNT 03109108 41 A0427RH 1 350.00 350.00 03109108 41 A0425RH 3 18.75 18f75: TOTALS 368.75 366.75' Less Amount Paid by Other Health Plan $295.00 ISSUED AMT: $73.75 For Questions Regarding This Claim P.O. BOX 14586 LEXINGTON, KY 40512 -4586 Total Patient Responatbility:.: $0.00 'I CALL (888) 632 -3862 FOR ASSISTANCE Claim Payment $73.75 Note: A# Inquides should reference the ID number above /or ptompt response. Total Pay t o: CITY O F CARMEL FIRE DEPT. $73 75 Protecting the privacy of member health information is a top priority at Aetna. When contacting us about this statement or for help with other questions, please be prepared to provide your Aetna provider number, tax identification number (TIN), or Social Security number (SSN), in addition to the Aetna member's ID number. L GUYED JUN 2 7 ZOO" XAetna P.O. BOX 981107 C LAIM <PA YMENT EL PASO, TX 79998 -1107 Please Retain for Future Reference 998213 J280DUNZ 923932 CITY OF CARMEL FIRE DEPT. PIN: 0005745100 CITY OF CARMEL FIRE DEPT. 2 CIVIC SQ CARMEL IN 46032 -2584 RECE ED JUN 2 7 2008 Coin A focSpecified Payer �D NO XXXXXXXX0972 CheC{('NO: 0495904 4 P Y P Y 9 Seq No .000010630 AccC 38208325 P:0 BOX 9811 U7 f rd,' rr y 7 r Ilil j'-9'::I pi "'ll� VIWgI" r r V�J�� it ��IiI�B i�IIG I �IIr III��IdPI ,3� �Y. PAYER B'P CORPLRATl ,N�NO,RTH AMERICA INC VAS- '�w1�� llw!��, 1 1* p si yF r l� �-,,.n i,,,{ gXLq r. N14d Iµ i��!IP lulUllll� 1 9�2 'i .kl :I� Y i lil Ili ,,I ill •I�� Bill ..;I,II� I�lil PAY �u m_. Iml Se�ren �,T +hree.Dolfars <and,75 /100 �::r I 11 i' '���4„� t i� l I A p r yR li;l'jI I V N r f� .1 %�yrll�� I V�I'll�o,�G� I�iT�ER !�I��r�R TO.THE CARML DEPTARTME T *0l0 CC k 73 47J ORDER ©F s 2 G'IV1 8Q 9 a "rui /r x $iuno you' o-.'a�w �IIII6,:, ,'s� Ihi v N71 a z n; „4 i� ,WI N I IIf lul,�i I .II 'VII I r :Y•a„ yinb '/��cr ;r /i ar err /nay£ New Costle DE 197,20 %3 r7 r ✓ni' of il(Piu7 10-2 y ti rr +rr III �I Il,l ul1ll it i I i srs �11I i�l dIP 111111, s h F lull NON" l vq llihlyul l I �I� I �IIIIItillll' I'll'll I II�Ig„ :fa.III II'' IV 0 4 :9 5.9.0`4.0 4ii• 4;e:0 3 ,L 0'0..20 o X313 2, °0 "8.3 "2.5111p•�PuhW: 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 an Purchase Order No. Terms 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 7 7 ld C /12 -4 i 72 7,f ON ACCOUNT OF APPROPRIATION FOR (�Atit' 2 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 AUG AIV 18 2008 2x Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund