176648 09/02/2009 CITY OF CARMEL, INDIANA VENDOR: 356246 Page 1 of 1
ONE CIVIC SQUARE AETNA
CARMEL, INDIANA 46032 PO BOX 14079 CHECK AMOUNT: $46.84
LEXINGTON KY 40512
CHECK NUMBER: 176648
CHECK DATE: 9!2!2009
DEPARTMENT mm ACCO UNT PO NUM I NVOICE NUMB AMOUN DESCRIP
102 5023990 46.84 OTHER EXPENSES
Aetna
August 10, 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: 200800442
Patient Name: MARTHA SHIREMAN Overpayment: $46.84
Member ID: W073939159 Bulk Pay Date: 04/15/2008
Control No: 397401 Service Date(s): 02111/2008
OP ID: 6645488
Dear Accounts Payable:
As explained in our letter dated July 7, 2009, an overpayment in the amount of $46.84 occurred on your bulk
payment dated April 15, 2008. 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 7, 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.
Page 2
Date of Letter: August 10, 2009
Subscriber: MARTHA SHIREMAN.
Member ID. W073939159
OP ID: 6645488
Thank you for your cooperation in this matter.
Sincerely,
Christian Flerx
Word Processor
Overpayment Recovery
National Accounts
"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-
Date: 08/18/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317 )571 -2605 FederalID# 356000972
d.F I TOR""'
Bill To: MARTHA L SHIREMAN ICD -9: 8730 7840 78079 E8859
12999 N PENNSYLVANIA ST
CARMEL, IN 46032
From: 12999 N PENNSYLVANIA ST
To: ST. VINCENT CARMEL
1 MEDICARE PART B
Patient: MARTHA L SHIREMAN 304367665A
12999 N PENNSYLVANIA ST Insurance
CARMEL, IN 46032 2 ANTHEM BC /BS 1 37010
Patient No: 200800442 R57861127
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
$312.50 $265.66 $46.84
CPT
Date Description Charges Credits
02/11/2008 BASIC LIFE SUP EMERGENCY A0429 $300.00
02/11/2008 MILEAGE A0425 $12.50
04/08/2008 MEDICARE PAYMENT $249.83
04/08/2008 ASSIGNMENT MEDICARE $0.21
04/25/2008 COMMERCIAL INSURANCE PAYMENT $46.84
05/23/2008 PAYMENT $15.62
08/18/2009 REFUND -46.84
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
A X Aetna u p A ae x �d� 07 Y Et B` I 7 °�Bd -1fQ7
Please Retain for Future Refer
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.Net nc` EL P,ti.50, Tr: 79946 -110;
R 13 L 7^ VED A P Q 2 u Z��� F!ease Retain for F-iture R�faren
L C117 c CAFM L FIRE DEPT I PI N: 00057451
?IjA Check No: 09817r0553708
Rage 5 0` 6 1
Patient Name: MARTHA SHIREMAN
Claim ID P8FAGDY500 Recd: 04108(08 Membe1 10: W073039159 Patent ACCUunt 200800442
tJlarndRl: YARTHA SHIREIAAN DIAL: 8736 7840 7807E
Giouo 'orme: GEN00RP NO GrcLi Numbee 397401.27 -616 AS 1) 8$FOf
Product: Open Choice0 Network ID. 00001
Aetna Life Insurance ComAanv
SER'ACE A SEAVYC= NUN' jLE rnl Ep AllCINA81_ CCPAY NOT ss "EE DEDUCTIBLE CD PRI IEN; P41f E
CAT- CODE SJCS CN8ACE5 ARIQJNT Ah.IQUNT PAYAELE PFKVRF:S lNSIIRNtiCE ncSF AldOINiT
021111109 1 4,1 1 1; 1 0.23
02/i1l08 A0 25{2 12.50 063
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TOTALS 212.50 9.Z1 15,82 15.62 2BB.6i
Less Amotir;t Paid by Other 1,'ea1h Plan 3249.
ISSUED AMT
Remarks
7 'Iccomring to e �r records, VOL' have agreed to accept the ameutl Modicara a poruvad as the charge tar this s=rvice. The mernberrs rzot legally
responsible ro nay more than trleoicare's approved amount.
a
r ❑t t i?atiern r2espansibdit f 515 6
ror Questto�s Reg�rding 1it15 Claim
P D FJX 981107, El PitSt}'_Tc 999$ 1 tD7 T E!
CALL (8$80 632 3882 FOR ASSISTAP4CE h p s4
as
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7�fa! Payment t�.• C17�Y OF C�4RMEL FIRF DEPT. �$1,ST9:0s.
'Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
n
Total,
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6.
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF$
ON ACCOUNT OF APPROPRIATION FOR
Board Members
Po 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
AU G- 3 1
Signature
Cost distribution ledger classification if Ti
claim paid motor vehicle highway fund