The URL can be used to link to this page

Home My WebLink About167945 01/21/2009 CITY OF CARMEL, INDIANA VENDOR: T0002820 Page 1 of 1 0 ONE CIVIC SQUARE CIGNA HEALTHCARE INC CHECK AMOUNT: $260.00 i! CARMEL, INDIANA 46032 PO BOX 182223 CHATTANOOGATN 37422 CHECK NUMBER: 167945 CHECK DATE: 1/21/2009 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 260.00 AMBULANCE REFUND STATE FARM EXPLANATION OF REVIEW 60 This is not a bill INSURANCE O State Farm Mutual Automobile CLAIM NUMBER 14- 2264 -035 OFFICE NAME Insurance Company Indiana MPC Office DANIEL YOUNT CARMEL FIRE DEPT EMERGENCY MEDICAL 1171 Driftwood Drive 2 CIVIC SQ Carmel, IN 46033 CARMEL, IN 46032 -2584 DATE OF LOSS 9/24/2008 CLAIM HANDLER Unit XB Processor NAME INSURED BACKES, CHRIS T LAURA M ADDRESS PO Box 2362 Bloomington, IL. 61702 POLICY NUMBER 150996014 PHONE 866 648 -0715 JURISDICTION Indiana ITIN 356 -00 -0972 Z IP OF SERVICE 46032 BILL REFERENCE NA DATE RECEIVED 12/11/2008 NUMBER 784.0 HEADACHE, E813.1 MOTOR VEHICLE COLLISION WITH OTHER VEHICLE, DIAGNOSIS CODES INJURING PASSENGER IN MOTOR VEHICLE OTHER THAN MOTORCYCLE, 873.0 OPEN WOUND OF SCALP WITHOUT MENTION OF COMPLICATION DRAFT NUMBER 1118608696J LINE DATE OF POS CPT/HCPCS MOD/TS UNITS SUBMITTED APPROVED REASON SERVICE AMOUNT AMOUNT CODES 1 9/24/2008 11 A0429 1 300.00 300.00 9/24/2008 2 9/24/2008 11 A0425 4 25.00 25.00 9/24/2008 TOTAL SUBMITTED CHARGES 325.00 TOTAL APPROVED AMOUNT 325.00 AMOUNT NOT PAYABLE 0.00 DEDUCTIBLE 0.00 APPORTIONMENT /PRO RATA 0.00 PAID AMOUNT 325.00 JAN 0 b �Utjto CLAIM NO 14- 2264035 POLICY NO 1509- 960 -14 LOSS DATE 09 -24 -2008 PAYMENT NO 1 18 608696 J Coverage 'Description Amount COL Pa �!td, DATE 01 -02 -2009 MEDICAL PAYMENT $325.00 600 2 AMOUNT $325.00 x T IN 14- 356000972 ENTERED BY STEPHENS DEBBIE *!AUTHORIZED BY STEPHENS, DEBBIE PHONE (866) 648 -0715 REMARKS 9/24/2008 ...M STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 18 608696 J WEST LAFAYETTE, IN JPMORGAN CHASE BANK, NA 56- 1544/441 COLUMBUS, OH Nf V114 NCB MPC INDIANA 18 -501 L025 01-02 -2009 CLAIM NO 14- 2264 -035 INSURED BACKES, CHRIS a DATE MM DD YYYY LOSS DATE 09 -24 -2008 ON BEHALF of DANIEL YOUNT *EXACTLY THREE HUNDRED FIVE AND 00 /,100,IDOLLARS *325.,00. Pav to the Order of: CARMEL FIRE DEPT EMERGENCY MEDICAL 2 CIVIC SCI CARMEL IN 46032- 2584�,�u 7 APPROVED BY CLAIM NO 14- 2264 -035 POLICY NO 1509 960 -14 LOSS DATE 09 -24 -2008 PAYMENT NO 1 18 608696 J Coverage Descri tion Amount Pay DATE 01-02-2009 MEDICAL PAYMENT $325.00 600 2 AMOUNT $325.00 TIN 14- 356000972 t 1 AUTHORIZED BY STEPHENS, DEBBIE PHONE (866) 648 -0715 REMARKS 9124/2008 FARM MUTUAL AIITOMQB LE INSURANCE COMPANY 60866 J WEST LAFAYETTE IN JPMORGAN GHASE COLUMBUS,' BANK NA 56 144%441 �usG ,NCq �MPC INDIANA COLD OH 0,1 -02 2009 CLAIM NO 4-2 2'.6 035 INSURED BA'CKES, CHRIS DATE 'Tn M nn LOSS DATE _Q9 -24 =2008= "BEHki:F .,DANIEL;YOUNT *EXACTLY THREE HUNDRED TWENTY -FIVE AND 0011OO.136LLARS *32 5.0.0 Pa the Order of CARMEL FIRE DEPT EMERGENCY MEDICAL 2 CIVIC SQ CARMEL IN 46032 -2584 AUTHORIZED.SIGNATURE II° b8 Z7608696�I° c:D1, 25 290 2 3 31I° 006794 CONNECTICUT GENERAL LIFE INSURANCE, COMPANY PHOENIX CLAIM OFFICE P.O. BOX 192223 CHA'17ANO0GA, TN 37422 -7223 CONNEC'FICU'T GENEKAL LIFE INSU1tANCE COMPANY CIGNA Healthcare AS AGENT FOR SEMICONDUCTOR COMPONENTS INDUSTRIES, LI C Provider Number: 356000972 0000 Date through which claims were processed. 10/31/2008 LI „LII „II,,,,�IInJ,I „1,1,1,1,1,.1 „I „III,,,,,LLI „II Pa CARMEL FIRE DEPT 919 2 CARMEL CIVIC SQ CARMEL IN 46032 -2584 now to Contact Us Mail to the return address in upper left corner of this page Phone: (800) 244 -6224 Provider Explanation oEMedicai Payment Understanding this Benefits Statement This page provides a summary of the payments made this period. The accompanying pages give more detail on the claims we processed for this period. Please review both the front and back of each page to see how the benefit amounts in the Provider Explanation of Medical Payment Report were determined. In the event a claim is denied...... Rights o f Review and Appeal For Physician or Health Care Provider If you have questions or disagree with the payment identified on this Explanation of Medical Payment Report, you may ask to have it reviewed. If you have a contractual agreement with CIGNA HeahhCare, please refer to the procedural guidelines associated with your C1GNA I lealthCare contract, or call our office for assistance. Rights o f Review and Appeal For Employee Call Member Services at the toll free number on this Explanation of Benefits (E0B) or your ID card if you have questions regarding this EOB. If you're not satisfied with this coverage decision you can start the Appeal process by submitting a written request to the address listed in your plan materials within 190 days of receipt of this E013 (unless a longer time is perm tted by your plan). Send a copy of this E013 along with any relevant additional information (e.g. benefit documents furt, clinical records) which helps to demonstrate that your claim is covered under the plan. Contact Member Services if you need her instructions on how and where to send your request for review. Be sure to include your 1) Name, 2) Operation Location /Group Number, 3) Eruployee /Patient ID number, 4) Name of the patient and relationship, and 5) Attention: App m Appeals Unit” on all supportinidocuents. You are entitled to receive free upon request access to, and copies o all documents, records and other information relevant to your claim for benefits. You will be notified of the final decision in a timely manner, as described in your plan materials. It your plan is governed by LRISA, you also have the right to bring legal action under section 502(x) of ERISA following our review. Payment SUMMary Check Num 0087 Chec Amoun $260.00 Check Date 10/31/2008 u2434C06 -26 -200(3 PRUCLAIM Medical Provider EOP Detach on Pertoration Below- Please Cash Promptly 0545 CONNECTICUTGENERAL LIFE INSUIUNCL COMPANY AS:AGENT FOR: 0 87 3 363 S) rMICONDUCTORCOMPONEN TSINDUSTRIES LLC .50,-947/213: DATE Provider CIGNA Rayi oc 919 10/31 /2008 356000972 OOOD TWO ,HUNDRED SIXTY ..;DOLLAR$ AND, 00 CENTS Pay CARMEL FIRE DEPT Uollars< *260. QO to the #`Z`CARMEL C?IVIC. >,SQ CARMEL IN 46 0 32 2584 Vold If Not Cashed Within 1 80 pays of JPMORGAN CE fi�SE SANK, N.A Ll SYRACUSE NEW YORK 3320484 THE IGINA 060C UMENT HA$ A REFLECtIVE WATERMARK, ON THE BACK? HOLD 'AT AN ANGLE:Tp VIEW G2434C06 -26. 2006 PROCLAkh1 i�AedreatProvider i:�' illiB 76 34 5 36 30 I.0 2 1309 3 79t: 60188 4957311• Date; 01/09/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032 (317)571 -2605 FederaiiD# 356000972 ACCOUNT H RY Bill To: BRADLEY YOUNT ICD -9: 8730 7840 E8131 1171 DRIFTWOOD DR CARMEL, IN 46033 From: 2450E 136TH ST To: CLARIAN HOSPITAL NORTH 1 CIGNA 5200 Patient: DANIEL YOUNT U2130902303 1171 DRIFTWOOD DR Insurance CARMEL, IN 46033- 2 Patient No: 200802317 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 $325.00 $585.00 260.00 CPT Date Description Charges Credit$ 09/24/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00 09/24/2008 MILEAGE A0425 $25.00 11/12/2008 COMMERCIAL INSURANCE PAYMENT $260.00 01/06/2009 COMMERCIAL INSURANCE PAYMENT $325.00 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 01/09/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federa]ID# 356000972 I HSTORY BiU To: BRADLEY YOUNT ICD -9: 8730 7840 E8131 1171 DRIFTWOOD DR CARMEL, IN 46033 From: 2450E 136TH ST To: CLARIAN HOSPITAL NORTH CIGNA 5200 Patient: DANIEL YOUNT U2130902303 1171 DRIFTWOOD DR Insurance CARMEL, IN 46033- 2 Patient No: 200802317 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 $325.00 $325.00 $0.00 CPT Date E Descnptlon Char es Credits 09/24/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00 09/24/2008 MILEAGE A0425 $25.00 11/12/2008 COMMERCIAL INSURANCE PAYMENT $260.00 01/06/2009 COMMERCIAL INSURANCE PAYMENT $325.00 01/09/2009 REFUND 260.00 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 a Provider Explanation o fiVedical Payment Report CIGNA Provider Nurnber Provider Name Date through which claims were processed TI IIS IS N A BILL Yage 356000972 0000 GARMEL >"IRE 10/30/20 DEPT Retain for Your Records 1 DRG/ Ad�uszed See Ptoceriure Add steel Billed Allowed Not Covered/ Deduct /Co v, Coinsurance DRGf DRG/ DRGfPer_Diem PerOlem hne Procedure Date Procedure Procedure Cod Benefit Plan Benefit Pa Per Diem Per.Dtem Code- Amount Amount :Discount Artioun[ Amount Code Amount' type Number Amount.: Amount Note PATIENT NAME: DANIEL R YOUNT PATIENT#: 200802317 OPERATION LOCATIDN /GROUP# 32486 -9- 3320484 RECEIVE DATE: 10/25/2008 PROCESS DATE: 10/30 MEMBER NAME: BRADLEY W YOUNT SUBSCRIBER UZ1309023 REF 9190829991463 CHECK 00876345363 1 09242008 A0429 300.00 300.00 60.00 0.00 0.00 240.00 3 i 09242008 A0425 25.00 25.00 5.00 0.00 0.00 20.00 i 2 TOTAL 325.00 325.00 260.00 f I i 52,200.00 HAS BEEN APPLIED TOWARDS THE $4,400 OUT OF NETWORK FAMILY DEDUCTIBLE FOR 2008 THE $2,200 IN NETWORK FAMILY DEDUCTIBLE HAS BEEN SATISFIED FOR 2008 j $2,866.62 HAS BEEN APPLIED TOWARDS THE 511,200 OUT OF NETWORK FAMILY 'OUT POCKET LIMIT' FOR f 2008 $2,860.62 HAS BEEN APPLIED TOWARDS THE $9,700 IN NETWORK FAMILY 'OUT OF LIMIT' FOR 2008 I I BALANCE $65.00 WHY WAIT FOR THE MAIL? VIEW ELIGIBILITY, BENEFITS OR CLAIM DETAILS ONLINE ANYTIME AT HTTP: /WWW.CIGNA.COM /HEALTH /PROVIDER/ PAYMENT OF $260.00 TO CARMEL FIRE DEPT 2��$ i MN2 RAO i i i II j I r I i I i I i I I G24-36D 03 -23 -2005 Proclaim Provider ECIP Summary h O Z V C Z 0 9 V Z O f I! I! !fl !I! II !IlII II! !I 1lII I I!!II Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995) ACCOUNTS PAYABLE VOUCHER 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 Q- Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) f o Total ,�`�p6 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 -1.5. 20 Clerk Treasurer VOUCHER NO. WARRANT NO. ALLOWED 20 IN SUM OF a��o CY C ON ACCOUNT OF APPROPRIATION FOR 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 AN 16 2009 Signature- Cost distribution ledger classification if Title claim paid motor vehicle highway fund