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Home My WebLink About176647 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 ea� USA Please Retain forFufure ReferRnc( CITY OF CARMEL FIRE DEPT. PIN: 000574510E Page I of 3 (2) CITY OF CARMEL FIRE DEPT. 2 CIVIC SQ CARMEL IN 46032 -2584 1flt, iJIL11111 1ttll111141111111ltltllllrrll1111111 1 Atli 11111 9dP6n..�M'.dnBFifibyLtt`SV8 o e I a 6Yt.:lrtEtN�4a -'S�'� r Aetna Life iA'brance,Company or amAt611aied Company `'�D NO ,XXXXXXX'XO972 Check Noi 067'231530 esAgent for Specdred Payers) Seq No 000000004 Aoct,09817 P.O: BOX 981107 �1 Ji EL PASO 7X- _78998 x USA a Z s o 14� fl Yq raf af4�A a 1 i 1l�ari 1i r'df 11y c7 51 A4 POLICYHOLDER .rte- MULTVPLE a I)wm� $�'>u�' e ��1(,I a 04 07 2009 q i��7 1� 1 Il aAr< r•a', �i. G lU 11ioY Yd •.:,r 1 xnz R, s,, llnw( rs f 11iYr 5 r I �;k fai; r;,,M yi r A �I f M p' Pats art r' �1 iLl ,0 2' [11C11Et�T2ll Qollars44'8 w” 7 r 4 k� m� i 151,4 R r i acgti k� �ysgw au W �A i kf d� r �w fl r fl 'k �1 ER IhN}iE 6u 4dvfl fH t i G� 1 Ol0;A l 5+T AR JO CARMELFIRE DE r PTARTMENT 9 i,(p mm' +tf,r# R s oR�ER of zc�u€c sca e" °8 n �la��r wz HN',�w� "��"�'f y' r rc v wW rua n d N ~Pa #.pa 4' "d �Wuim,»' �.M�.ua'dn�' f �dr akdf�'1riNYF vm'�.:: „t p �!4+ �1 9 a d 1' Gf i2 hu 1 fl 4, 4 Ali 1} �u a hav 0 6 0 it u 1 900'4 51. 00000000 98 i 7;11 UC] /]I J1KGFJ15 II /.Sb11U )q P.O. PDX 9811 D7 EL PASO. TX 79998-1107 BXPL.ANATiON OF'BENEFITS etn I l US Fl Please P,efain for Future Referenc 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: $110.8f 1111111 411 1111, 1111111 411111111 11111 11111IIILIIIIII III Irlll 11 Notes: Update your address, telephone number. email address and/or NPI information by visiting viww.aetna.comlprov-oiebi or www.aetnadental.com and select Update Personal Information, Patient.Name: MARTHA SHIREMAN (Self) Claim ID: PYYZFLY9A00 Recd: 04/03/09 Member H7: W073939159 Patient Account: 200900279 Member: MARTHA SHIREMAN DIAG: 780607245 4019 Group Name: GENCORP INC Group Number, 397401-27-016 AS DBSF00 Product: Open Choice0 -Nehvork ID' 00000 Aetna Life Insurance Company SEPVICE, PL. SEPVICE NUM SUErAITTEp ALLO`a1SEtE COFkY hlt:�T SEE pEDI!C11P,LE c0 FS'rl�lir f'wo.Blf_ DATES CODE SVGS CHARGES AMOUNT AIAOurIT FA,YAFLE RINAN',1 IIISUF7.11!;E F.FP Ar7p lNli 01120/09 41 A0427RH 1.0 375,00 1g ?S 187; 01/26109 41 A0425RH 2.0 13-10 4 ;r TOTALS 398.10 19.41 19.41 368.6! Less Amount Paid by Other Health Plan ISSUED AMT: Continued on Next Page q Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995) CITY OF CARMEL An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. ,fJ Payee Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) /2 Q Total a I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance with IC 5- 11- 10 -1.6. 20 Clerk- Treasurer ./OUCHER NO., WARRANT NO. ALLOWED 20 IN SUM OF$ 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