176647 09/02/2009 CITY OF CARMEL, INDIANA VENDOR: 356246 Page 1 of 1
ONE CIVIC SQUARE AETNA
CARMEL, INDIANA 46032 PO a0X 931 107
CHECK AMOUNT: $58.21
EL PASO TX 79998 -1107
CHECK NUMBER: 176647
CHECK DATE: 9/2/2009
DEPARTMENT AC COUN T PO NUMBE INVOICE NUM AMOUNT DESCRIPTION
102 i 5023990 58.21 OTHER EXPENSES
Date: 08/18/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal 1D# 356000972
B
Bill To: MARTHA L SHIREMAN ICD -9: 78060 7245 4019
12999 N PENNSYLVANIA ST APT 306D
CARMEL, IN 46032
From: 12999 N PENNSYLVANIA
To: ST. VINCENTS HOSPITAL CARMEL
1 MEDICARE PART B
Patient: MARTHA L SHIREMAN 304367665A
12999 N PENNSYLVANIA ST APT 306D Insurance
CARMEL, IN 46032 2 ANTHEM BC /BS/ 37010
Patient No: 200900279 R57861127
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$388.10 $329.89 $58.21
CPT
Date Description Charges Credits
01/20/2009 ADVANCED LIFE SUPP 1 —EMER A0427 $375.00
01/20/2009 MILEAGE A0425 $13.10
03/31/2009 MEDICARE PAYMENT $310.48
04/14/2009 COMMERCIAL INSURANCE PAYMENT $58.21
07/17/2009 PAYMENT $19.41
08/18/2009 REFUND
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
)(Aetna-
August 11, 2009 AETNA
PO BOX 14079
LEXINGTON, KY 40512 -4079
CITY OF CARMEL FIRE DEPT.
2 CIVIC SQ
CARMEL, IN 46032 -2584
Plan Sponsor: GENCORP INC
Employee: M SHIREMAN Account Number: 200900279
Patient Name: MARTHA SHIREMAN Overpayment: $58.21
Member ID: W073939159 Bulk Pay Date: 04/07/2009
Control No: 397401 Service Date(s): 01/2012009
OP ID: 6648938
Dear Accounts Payable:
As explained in our letter dated July 8, 2009, an overpayment in the amount of $58.21 occurred on your bulk
payment dated April 7, 2009. The reason for the overpayment was benefit payment should have been made by
another insurance carrier. The Primary Payor is Anthem Federal Blue Cross. We will reprocess this claim based
on the terms of this plan when the other carrier's explanation is received.
This plan's coordination type is maintenance of benefits (MOB). Under MOB, Aetna's benefits as the secondary
plan are maintained and are not contingent on the primary carrier's allowable amount. The provider can accept
payments that total up to the Aetna allowed amounts.
Please make your check or money order payable to Aetna. Please attach your payment to a copy of this letter and
return it to ensure proper identification and credit to your file. If you have mailed your payment please disregard
this letter.
We apologize for any inconvenience this may have caused. However, at this time we must request that you return
this overpayment. If payment is not received by September 8, 2009, we will deduct the overpayment by offsetting
a future payment. If the overpayment is not eligible in our system for offsetting, we may refer the overpayment to a
recovery service. If you have any questions regarding this overpayment, please feel free to contact this office at
888 632 -3862 or write me at the above address.
"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 benefit coverage include Aetna Health Inc., Aetna Health of California Inc., Aetna Health of the
Carolinas Inc., Aetna Health of Illinois Inc., Aetna Life Insurance Company, Aetna Health Insurance Company of New York, Corporate Health
Insurance Company, Aetna Dental Inc., Aetna Dental of California Inc., Aetna Health Administrators, LLC, and Aetna Health Management,
LLC.
P.O. BOX 98 „07 CLAIM. AA YMENT
EL PASO, TX 79998.1107
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USA
Please Retain forFufure ReferRnc(
CITY OF CARMEL FIRE DEPT. PIN: 000574510E
Page I of 3 (2)
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CITY OF CARMEL FIRE DEPT. !PIN: 00057451 C
Check No: 093171067231a
Page 2 of 3 (2)
Date Printed: 04107/200c
CITY OF CARMEL FIRE DEPT. Tax Identification Number: XXY,XXXXX097,
2 CIVIC SO Check Number:. 0981 7/06723153C
CARMEL IN 46032 -2584 Check AmCUnt: $110.8f
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Notes:
Update your address, telephone number. email address and/or NPI information by visiting viww.aetna.comlprov-oiebi or
www.aetnadental.com and select Update Personal Information,
Patient.Name: MARTHA SHIREMAN (Self)
Claim ID: PYYZFLY9A00 Recd: 04/03/09 Member H7: W073939159 Patient Account: 200900279
Member: MARTHA SHIREMAN DIAG: 780607245 4019
Group Name: GENCORP INC Group Number, 397401-27-016 AS DBSF00
Product: Open Choice0
-Nehvork ID' 00000
Aetna Life Insurance Company
SEPVICE, PL. SEPVICE NUM SUErAITTEp ALLO`a1SEtE COFkY hlt:�T SEE pEDI!C11P,LE c0 FS'rl�lir f'wo.Blf_
DATES CODE SVGS CHARGES AMOUNT AIAOurIT FA,YAFLE RINAN',1 IIISUF7.11!;E F.FP Ar7p lNli
01120/09 41 A0427RH 1.0 375,00 1g ?S 187;
01/26109 41 A0425RH 2.0 13-10 4 ;r
TOTALS 398.10 19.41 19.41 368.6!
Less Amount Paid by Other Health Plan
ISSUED AMT:
Continued on Next Page
q Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
,fJ Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
/2 Q
Total a
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6.
20
Clerk- Treasurer
./OUCHER NO., WARRANT NO.
ALLOWED 20
IN SUM OF$
D x
Z VO 7 9
VD5
z
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #fTITLE AMOUNT
DEPT. 1 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
AU 3 1 2009
20�
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund