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Home My WebLink About179455 11/11/2009 CITY OF CARMEL, INDIANA VENDOR: T0002825 Page 1 of 1 ONE CIVIC SQUARE UNITED HEALTHCARE CARMEL, INDIANA 46032 PO BOX 740603 CHECK AMOUNT: $67.12 ATLANTA GA 30374 -0803 CHECK NUMBER: 179455 CHECK DATE: 11/11/2009 DtPARTMFNT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 67.12 REFUND Date: 10/28/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317 )571 -2605 FederaliD# 356000972 Bill To: DOROTHY M WINSTEAD ICD -9: 9593 71943 E8801 8720 YARDLEY COURT APT 204 INDIANAPOLIS, IN 46268 Frain: 1217 S RANGELINE RD To: ST. VINCENTS HOSPITAL CARMEL 1 THE HARTFORD Patient: DOROTHY M WINSTEAD CLM #22WBIT2939 8720 YARDLEY COURT APT 204 Insurance INDIANAPOLIS, IN 46268- 2 AARP /UNITED HEALTHCARE Patient No: 200901704 015805521111 PLEASE DO NOT PAY! THIS IS NOT AN INVOICE! WE HAVE BILLED YOUR HEALTH INSURANCE. NO PAYMENT IS DUE FROM YOU AT THIS TIME. PLEASE FILL OUT THE SURVEY ON THE BACK SIDE AND RETURN IN THE ENCLOSED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $338.10 $673.71 335.61 CPT Date Description Charges Credits 07/03/2009 BASIC LIFE SUPP EMERGENCY A0429 $325.00 07/03/2009 MILEAGE A0425 $13.10 09/01/2009 MEDICARE PAYMENT $268.49 09/01/2009 ASSIGNMENT MEDICARE $2.49 09/22/2009 COMMERCIAL INSURANCE PAYMENT $338.10 09/24/2009 ASSIGNMENT MEDICARE -2.49 09/29/2009 COMMERCIAL INSURANCE PAYMENT $67.12 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 10/28/2009 a CARMEL. FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317 )571 -2605 FederalID# 356000972 g 0 r Bill To: DOROTHY M WINSTEAD ICD 9: 9593 71943 E8801 8720 YARDLEY COURT APT 204 INDIANAPOLIS, IN 46268 From: 1217 S RANGELINE RD To: ST. VINCENTS HOSPITAL CARMEL 9 THE HARTFORD Patient: DOROTHY M WINSTEAD CLM #22WBIT2939 8720 YARDLEY COURT APT 204 Insurance INDIANAPOLIS, IN 46268- 2 HARP /UNITED HEALTHCARE Patient No: 200901704 015805521111 PLEASE DO NOT PAY! THIS IS NOT AN INVOICE! WE HAVE BILLED YOUR HEALTH INSURANCE. NO PAYMENT IS DUE FROM YOU AT THIS TIME. PLEASE FILL OUT THE SURVEY ON THE BACK SIDE AND RETURN IN THE ENCLOSED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $338.10 $606.59 268.49 CPT Date Description Charges Credits 07/03/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 07/03/2009 MILEAGE A0425 $13.10 09/01/2009 MEDICARE PAYMENT $268.49 09/01/2009 ASSIGNMENT MEDICARE $2.49 09/22/2009 COMMERCIAL INSURANCE PAYMENT $338.10 09/24/2009 ASSIGNMENT MEDICARE -2.49 09/29/2009 COMMERCIAL INSURANCE PAYMENT $67.12 10/28/2009 REFUND -67.12 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 261- AARPCK42•01171. 001 -03418 UNITED HEALTH CARE If you have questions please contact us at: PO BOX 740819 ATLANTA, GA 30374 -0819 UNITED HEALTH CARE PO BOX 740819 ATLANTA, GA 30374 -0819 TOLL FREE: 1- 800 -AARP- 789 1- 800 2277 -789 PAGE 1 OF 4 CARMEL FIRE DEPT* 2 CARMEL CIVIC SQ CARMEL IN 46032 -7543 REMITTANCE ADVICE PLEASE RETAIN FOR YOUR RECORDS STATEMENT DATE: SEPTEMBER 1 8 2009 RECEil E 9 2009 CHECK AMOUNT: $1,505.93 For real -time access to claim, check, and member eiiVgibility information please register online at. https://aarpprovideronlinetool.uhc.com Please remember to submit your claims on a timely basis. The certificate of insurance includes a time limit for submitting proof of loss. Any person who knowingly and with intent to defraud any insurance compaliy or other person fifes an application for insurance or statement of claim containing any materially false information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Health Care United HealdiCare Insurance Company (and United Health Care insurance Options 0 Company of Nevi York for New York residents) are proud providers to Q Please detach check below and cash promptly aptly 'UNtTED,HEALTH CARE L Qa i3o' 740819 62 20 ATLANTA =GA 30374 0819 CrtiO Delaware 311 0. One Penn 's 'Way Y New Castle, DE 1.9720 f REPRESENTS PAYMENT; FOR MULTI PLE,INS ORE'DS i= DATE' SEPTEMBER =z 4 PAY 505 93** ONE THOU:SAND FIVE HUNDRED FIVE. DOLLARS :AND 9.3 CENTS* PAY TO THE, ORDER 'OF CARMEL.,.FIRE .;DEPT* 2.CARMEL CIVIC SQ CARMEL TN 46032 =7543 ,2:x,10,0 2 2'8118 1 0 3 L L:0:0 ._2 0 91: 38 5 0 2:1 E, 4111, 261- A.ARPC X42- 01171- 002.03419 Health Care United HealifiCare Insurance Company (and United HcohhCare Insurance Options Company of New York for NevN York residents) are proud providers to PAGE 2 OF 4 REMITTANCE ADVICE PLEASE RETAIN FOR YOUR RECORDS STATEMENT DATE: SEPTEMBER 18, 2009 BENEFIT SUMMARY FOR: CARMEL FIRE DEPT* SEP 2 9 2009 Insured Provider Dates of Amount Medicare Medicare Applied to Benefit information Service Charged Approved Paid Deductibie From To BENEFIT BASED ON THE AMOUNT APPROVED BY MEDICARE. 4 WINSTEAR, DOROTHY M ,.,'ti r: MEMBERSHIP' 015805521 CLAIM 92446 507'052 1 ATIENT 20�090i704� CARMEL' 070309 325.00 322.51 258.01 64.50 CARMEL 070309 13.10 13.10 10.48 2.62 TOTAL 67.12 800 5-2 1 910 7 The Hartford Central Work Comp PO Box 14471 Lexington, KY 40512 877 952 -9222 THE IARTFORD 000950 City Of Carmel Fire Department 2 CIVIC SQUARE CARMEL, IN 46032 Attention This remittance Encorporates 1 claim payments Special Handling ID: RM 00 m m 0 0 0 RE GEIVED S E P 2 2 2009 083718583 HAR -100 -2 e e e e The Hartford.- Central Work Comp i 56 :154 C heck` Number 1140838571 PO;Bo0447.1 :x441 ss u e? D ate 09 -1' 1 -2009 H E Lexington, KY 40512 9 ,e �'I�IIARTFOZ w, 5 877.952 9222 1 ni s lii "w1y; ti4 q yr 7° 4 7➢ 1sYi 17 t51 N i 1r ,�i '4,' r JP.Morgan r2w ti ChasesBank NA ti:J'1d a ye` Columbus, OH<43085 THREE HUNDRED THIRTY -EIGHT DOLLARS AND 10 /100 M w TO THE ".A City 0f Carmel Fire Depart "mentFx ,r 2 =ORDER 2 CIU,IC:�SOUARE,�, �xr CC OF CARMEL, iN 46032 Tr `AUthorized Signature r II' b 04083857 �I1' 1:01 1 b54L.31: 63 255973Bo Bill Control No: THE HARTFORD MEDICAL BILL PROCESSING CTR 0127492877 P.O. BOX 14170 1124 LEXINGTON, KY 40512 EXPLANATION OF REIMBURSEMENT September 11, 2009 PATIENT: DOROTHY WINSTEAD SOC SEC NO: XXX /XX/2608 CLAIM NO:YKS 05210 C INJURY DATE: 07/03/2009 INSURED: NEW CONCEPTS IN MARKETIN INVOICE NO: 200901704 PAY TO: CITY OF CARMEL FIRE DEPARTMENT INVOICE DATE: 08/17/2009 2 CIVIC SQUARE CARMEL, IN 46032 TAX ID NO: 356000972 PROCEDURE DESCRIPTION CHARGED PAID cti N O 07/03/2009 TOS: DIAG CD: 959.3 UNITS: 00001 A0429 SH AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERG TRA 325.00 325.00 REASON: REIMBURSEMENT IS BASED UPON USUAL, CUSTOMARY AND REASONABLE RATE FOR YOUR GEOrRAPHIC (ZIP CODE) AREA. m 0 07/03/2009 TOS: DIAG CD: 959.3 UNITS: 00001 A0425 SH GROUND MILEAGE. PER STATUTE MILE 6.55 6.55 0 0 REASON: REIMBURSEMENT IS BASED UPON USUAL, CUSTOMARY AND REASONABLE RATE FOR YOUR GEOGRAPHIC (ZIP CODE) AREA. 07/03/2009 TOS: DIAG CD: 959.3 UNITS: 00001 A0425 SH GROUND MILEAGE, PER STATUTE MILE 6.55 6.55 REASON: REIMBURSEMENT IS BASED UPON USUAL, CUSTOMARY AND REASONABLE RATE FOR YOUR GEOGRAPHIC (ZIP CODE) AREA. RECEIVED S E F 2 2 2009 CHARGED AMOUNT: 338.10 TOTAL AMOUNT PAID: 338.10 For Reconsideration of this reimbursement determination, the following information MUST be submitted: Copy of this EOR, copy of the original bill and any supporting documentation to the address above. If you have any questions regarding this Explanation of Reimbursement (EOR) please call 800- 526 161 1 and reference your Bill Control Number 0127492877• eon Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995) CITY OF CARMEL Ar^voice 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 n/ Purchase Order No. '11 ,),,x 7 zhQ ?Z q Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) S7ZP Total Z Z 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 r VOUCHER NO. WARRANT NO. ALLOWED 20 IN SUM O F �o Z Z2 6 C 7� Y/ 9 A6/ZA s l 7. /z 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 N 20 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund