161518 07/11/2008 CITY OF CARMEL, INDIANA VENDOR: T0002492 Page 1 of 1
j ONE CIVIC SQUARE PHYSICIANS MUTUAL INSURANCE CO
CARMEL, INDIANA 46032 PO Box 2018
CHECK AMOUNT: $73.75
OMAHA NE 68103
CHECK NUMBER: 161518
CHECK DATE: 7/11/2008
DEPARTMENT ACCOUNT PO NUMBER IN VOICE NUMBER AMOUNT DESCRIPTION
102 5023990 73.75 OTHER EXPENSES
Date: 07/01/2008
CARK0EL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL. IN 46032-
(317)571-2805 p*dora/uD# 356000872
Bill To: MARY B LEISURE ICD-9: 78609 7867 7862 7823
1O4O EAST 1O8THSTREET
INDIANAPOLIS, IN 46280 From: 1040 E 108TH ST
To: ST. VINCENT-CARMEL
1 MEDICARE PART B
Patient: MARY BLEISURE
1O4O EAST 1OOTHSTREET Insurance
INDIANAPOLIS, IN 48280 2 UNITED HEALTH INS/30555
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
CPT
Date Descriotion, Charoes Credits
03/09/2008 ADVANCED LIFE SOPP l-EMER A0427 $350.00
0310112008 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
APPROVED ov THE STATE BOARD nF ACCOUNTS FOR CITY OFC*nMEL.1ege
Date: 07/01/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
ACCOUNT T Z
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
f 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
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Physicians Physicians ]Mutual Insurance Company
Mutt.lal" Physicians Life Insurance CompanyO
;April 28. 2008
Tax ID No. 316000972
Draft No. 018112172
Explanation of Benefits
i\ [ed�cai e
\'iedicare Medicare Nledica�e P)II('
1S �l :1 i o� el 1)cduct. Pail Paid
I, uie I <<ftcut k* cca. No Iaticnt itamc: 5c►� C.Lum o 13d1c. PP
No O1'I13 (o�if� of N ll ite cif l3u th I) �te(ti) I)csct option of Sep A jce Tee 1'or nuig P o� ale j
001 -07 200800697 1�1ARY 13 LEISIIR1 0309% 2008 VQl)8597 -0 368.75 368.75 0.00 295.00 73.75
110809 05;'27x'1 4 03/09,2008 fart 13 ldedical 13enetit C \RMEL FIRE Dl P.AR lAIBN"I
002 -08 200800694 M JE_1NNENE ENLEX 03/09x2008 VQ1 -0 387.50 387.50 0.00 310.00 77.50
1108095058290 09'17/37 03!09 -'2008 Part 13 Medical 13enel3t C IUVIEL FIRE DEPARTMENT
o f.......... .lniount nclosc;l
RS Claims may now be sent to us electronically via our Clearinglwuse. l nxieon.
using our Payor ID number 47027. NOTE: Do not send Medicare supplement
claims as they are received directly from the Medicare carriers.
RP All adjushneirt claims nriv nol be received electronically. ll'there is no
indication on the \Medicare statement ol'the claim being forwarded to us.
please send paper copies ol'all monetary adjustments Ivor our consideration.
HCEIVED MAY 7 2006
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RECEIVED MAY 0 7 2008
N226 -1106
PHYSICIANS NIUTU I1\TSURANGE COMPANI'�
OAla7Ia,N�131LaS1%A:68131 PAYABLETBROUGH 7G -a
II li FII ST NA7 ZONAL BAMi OF OAfAHA 10 f 9
ONLAHA, NEBRASKA U;10
FREn401 NA710 N4L B4 \'I E IRUS I'l.O
,.1,923 FREN1ONl NEBRASIi,�
CLAIM
DATE DRAFT NO: ANIC)UNT
04i'Z R!08 018412172 -1
$151.25
T13E ORDER D1
y o
CAR MEL FIRE-DI;P ARTMENT
2 CARMEL CIVIC'SQ
CARMEL IN 46032
f
II °0 L84 1 2 L7 211 I: L0 9000481: 09 LO Laa7 II°
Overpayment Recovery
l P.O. Box 14079
Cketna
Lexington, KY 40512 -4079
06 -16 -2008
DCN# 080616224220
CITY OF CARMEL FIRE DEPT
2 CIVIC SQ
CARMEL, IN 46032 -2584
III1111111111111111111111111
Patient Name: MARY
Member ID: W102839647
Date Of Service: 03 -09 -2008
Acct/Invoice n/a
Check Date: 04 -29 -2008
Check Number: 49590404
Check Amount: $73.75
Check [D:080516520288
Dear Health Care Professional:
Thank you for your refund check noted above. Unfortunately, we cannot credit the funds and are returning this
check for the reason below:
The claim has been paid correctly as secondary to Medicare under this subscriber's Aetna plan. If you still
feel the patient's claim is overpaid please send a copy of the Explanation of Benefits showing the other
payment. If the other payment was made by AARP or an individual policy then the refund would either be due
to them or the patient.
Based on the information available, Aetna determined that this claim has been paid correctly under this
subscriber's Aetna plan. If it is later determined that there was an overpayment on these claims, Aetna
reserves the right to pursue such overpayments.
If you have any questions or comments, please feel free to contact our office at 888 -632 -3862 or visit the
following Aetna website: www.Aetna.com
Sincerely,
&x F
Cathy Fisher
Recovery Savings Analyst
RECEIVED JUN 2 7 ZUU8
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. The Aetna
companies that offer, underwrite or administer benefits coverage include Aetna Health Inc., Aetna Health of California Inc., Aetna Health
of the Carolinas Inc., Aetna Health of Illinois Inc., Aetna Dental Inc., Aetna Dental of California Inc., Aetna Health Insurance Company of
New York, Aetna Health Insurance Company and /or Aetna Life Insurance Company.
P.O. BOX 981107 C LAIM ;PA YMEV.T
®et' USA EL PASO, TX 79998 -1107
1 Please Retain for Future Reference
008213 JZ80DUN2 923032 CITY OF CARMEL FIRE DEPT. PIN: 0005745100
CITY OF CARMEL FIRE DEPT.
2 CIVIC SQ
CARMEL IN 46032 -2584
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TO THE CARMEE FIRE DEPTARTMEN7 C
w �II111u1 Illulb 011ga)Ilu v Itln a IP)�'i1119I 111 hq III P >f4 yr $�73Z5
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�Aet na IJSA P O BOX 981107 Ex PLANI T! EL PASO, TX 79998 -1107 Please Retain for Future Reference
008213 J280DUA2 023034 CITY OF CARMEL FIRE DEPT. I PIN: 00057451 0(
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 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: provider /eraeft_enrollmeent.html to learn more and to register.
P��E•in d�C`nne OVIAIRY B f �OSU F RE (iJev)
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: :ICOPAY NOT SEE DEDUCTIBLE CO PATIENT ::PAYABLE
DATES CODE SVCS '..CHARGES AMOUNT AMOUNT PAYABLE REMARKS :INSURANCE -.RESP ::AMOUNT
03109108 41 A0427RH 1 350.00 350.00
03109108 41 A0425RH 3 18.75 18.75
TOTALS 368,75 366.75'r
Less Amount Paid by Other Nealth Plan $295.00
ISSUED AMT: $73.25
For Questions Regarding This Claim P.O. BOX 14586.LEXINGTON, KY '40512 -4586 Total Patient Respons)blllty
CALL (888) 632 =3862 FOR ASSISTANCE
Note: All Inquiries should reference the ID numberabove for prompt response
Claim Paymeht. $73.75:
Total Paymen to: CITY OF 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.
gASG i�1�I? JUN 2 7 20��
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
zsy t
S Lc" Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
V2
SI
f U
v
t
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
SiL'i ��1 s IN SUM OF 73 7S
ON ACCOUNT OF APPROPRIATION FOR
4md Zj" r d/ to 4 ary
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
0 1J"Ga1
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund