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211879 08/14/2012 CITY OF CARMEL, INDIANA VENDOR: T359706 Page 1 of 1 0 ONE CIVIC SQUARE NATIONAL GOVERNMENT SERVICES CHECK AMOUNT: $972.53 CARMEL, INDIANA 46032 PO BOX 809312 .Qa CHICAGO IL 60680-9312 CHECK NUMBER: 211879 CHECK DATE: 8/1412012 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 972 . 53 OTHER EXPENSES OO ©0 lLJ 0{7 El CITY OF ARMEL JAI\,IES BRAINARD, MAYOR August 13, 2012 National Government Services P.O. Box 809312 Chicago, IL 60680-9312 RE : David Clifford 429061776A Claim 221812114757220 and 22181211457230 Dear Sir/Madam: Enclosed you will find a reimbursement check in the amount of$972.53. June 27, 2012 we received payment from Cigna for ambulance transport on March 4, 2012 for $469.39 and $503.14. David Clifford's Primary insurance is Cigna. Since Cigna is primary, we are issuing Medicare a refund of$972.53. If you have any questions, please feel free to contact me at (317) 571-2604. Sincerely, 1110�1 ' Michelle T. Harrington Billing Administrator CARMEL FIRE DEPARTMENT STEVEN A. COUTS HEADQUARTERS T«,o CR IC SQUARE, CARAIEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615 MEDICARE Part B .............................................................................................. .... ................................................................................................ Letter Number: 10345405 Date: 07/23/2012 CITY OF CARMEL 2 CIVIC SQUARE CARMEL, IN 460322584 RE : Overpayment Amount: $972.53 Outstanding Balance: $972.53 Provider Number: 1154325579 Dear Sir/Madam, This is to let you know that you have received a Medicare payment in error which has resulted in an overpayment to you of $972.53. The attached listing explains how this happened. Why you are responsible: You are responsible for following correct Medicare filing procedures and must use care when billing and accepting payment. You are responsible for repayment in this matter based upon one or both of the following criteria: 1. You billed and/or received payment for services for which you should have known you were not entitled to receive payment. Therefore, you are not without fault and are responsible for repaying the overpayment amount. 2. You received overpayments resulting from retroactive changes in the Medicare Physician Fee Schedule and/or changes mandated by legislation. If you dispute this determination please follow the appropriate appeals process listed below. (Applicable authorities: Section 1870(b) of Social Security Act; subsections 405.350 - 405.359 of Title 42, subsections 404.506 - 404.509, 404.510a and 404.512 of Title 20 of the United States Code of Federal Regulations.) What you should do: National Government Services, Inc. P.O. Box 6160, Indianapolis, IN 46206-6160 www.NGSMedicare.com Page 2 Date : 07/23/2012 Letter Number : 10345405 Please return the overpaid amount to us by 08/21/2012 and no interest charge will be assessed. Make the check payable to Medicare Part B and send it with a copy of this letter to: National Government Services, Inc. P.O. Box 809312 Chicago, IL 60680-9312 You may elect to have your overpayment(s) repaid through the immediate recoupment process and avoid paying by check or waiting for the standard recoupment that begins on day 41 from date of the initial demand letter. A request for immediate recoupment must be received in writing no later than 16th day from the date of initial demand letter. You must specify whether you are submitting: 1. A one-time request for the current overpayment and all future overpayments, or 2. A request for the current overpayment addressed in this demand letter only. This process is voluntary and for your convenience. Visit our website at www.NGSMedicare.com for additional information and instructions for Immediate Recoupment. You may fax your request to the number mentioned at the end of this letter. If you do not refund in 30 days: In accordance with 42 CFR 405.378 simple interest at the rate of 11 percent will be charged on the unpaid balance of the overpayment beginning on the 31st day. Interest is calculated in 30-day periods and is assessed for each full 30-day period that payment is not made on time. Thus, if payment is received 31 days from the date of final determination, one 30-day period of interest will be charged. Each payment will be applied first to accrued interest and then to principal. After each payment interest will continue to accrue on the remaining principal balance, at the rate of 11 percent. We request that you refund this amount in full. If you are unable to make refund of the entire amount at this time, advise this office immediately so that we may determine if you are eligible for a repayment plan. (See enclosure for details.) Any repayment plan (where one is approved) would run from the date of this letter. If payment in full is not received by, 09/01/2012, payments to you will be withheld until payment in full is received or an acceptable extended repayment request is received. If you have reason to believe that the withhold should not occur on 09/01/2012 you must notify National Government Services, Inc. in writing before 08/06/2012. We will review your Invoice Number: 224712198213010 Claim No. Beneficiary Name HIC No. Service Date Service Date Amount Paid Date Performing From To Overpaid Provider No. 221812114757220 DAVID CLIFFORD 429061776A 03/04/2012 03/04/2012 $469.39 05/07/2012 1154325579 Reason for Overpayment: The claim was processed and paid with Medicare as the primary coverage. Medicare should have paid secondary to Disability coverage. Invoice Number: 224712198214000 Claim No. Beneficiary Name HIC No. Service Date Service Date Amount Paid Date Performing From To Overpaid Provider No. 221812114757230 DAVID CLIFFORD 429061776A 03/04/2012 03/04/2012 $503.14 05/07/2012 1154325579 Reason for Overpayment: The claim was processed and paid with Medicare as the primary coverage. Medicare should have paid secondary to Disability coverage. 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)) 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#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 AUG 18 1012 L Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund