167945 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