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212378 08/28/2012 CITY OF CARMEL, INDIANA VENDOR: 360209 Page 1 of 1 is ONE CIVIC SQUARE ST VINCENT'S CARMEL HOSPITAL 4 13500 N MERIDIAN STREET CHECK AMOUNT: $696.00 . % CARMEL, INDIANA 46032 CARMEL IN 46032-1456 CHECK NUMBER: 212378 CHECK DATE: 8/28/2012 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1201 4358800 696 . 00 TESTING FEES — — / CITIZILNG Po Box C-20 CREATION DATE 1�0511_ 001 PAGE OF 040-4 1639124134 ri VIM ' � �.� `` AUG 2 7 2012 zOU'd O%8CC89LTu '1uo9 m00 G4a ov:Go CTon-oT-1uc By kT VINCENT CAMIS�, xOSPITA tT v:r•CENT CAPYIE ........ �Y I.z.ELI-ABLE PKWY _c'd 131 -T 1,00 X ME R I 6i.AN STIRY-12 ...... L.... .................... 7 11 122e ......... 14310"t .5 2 —0 M 04 «221;11 n ................. WORKrM COT"r a 49 10 CITIZENS mANAGr1M-NT b t""' Po nor. 620 WOWMLL, MI 40044 770101 Yn •0300 A-11Y a. 'z L_.- ........... . ........... t —w. w, ri 0001 PAGE 1 OF GREATM DA 010412 • 07 00 1 - — , , 1673!1'24134 U7 00 WC qVIII-zNr y ......... au lrf IM MID a=Pro,*�,;477 IR CITY OF CAKME ik' 'aL 'V70 L A tweg bat 74 NC.ENT LAm CT v! L. COMP 32 2N v ............ LAO diYffL-N'�"f.AN1A5*-tENT 7T-, Tame�:= Q AUG 2 7 2012 600'd OZ86689 y 'IAO!D NON Sdd TV:60 ZIOZ-ZI-InP 802PITA 1ST L ...57_.VINCENT_-CA.PJ142Y.1405PITA 13500 N y1Z--*i-!'iir1;`1q4V:;4;.j !31 ..��RZDIAN STREET 1207 RELTA LE PK'4y 90 jq�.�L IN 460521456 _I L.6 0 6 :173388039 - 1011C12 zwa;"=71 A ' r ?gtltiq tv 0- 01, w: r?10411; T_XCITY OF CANMEL ONE CIVIC SQUAKb 45 23 CA;LMML, IN 46012 ,10300 ni .00 501 01i -pre nnIma-, %fl ............. ';;L4 Vj it.: .......... nmn% 11 001 1 PAGE--.L OF CREATION vArE 1 012 412 kjq 9; •fi 0 Stitt, CITY OF CAKMEL 499 ou .......... t 7wZ F7 t L G 704: V 1.0 4 Jw FhLtJL)KlYTHA.L IFP=WILLIAM xC TY ONE CfqlC 3OUARE Tz ................... . AUG 2 7 B Ey 2012 V00'd 098SC89LI 'IAOE) NON Sid ":60 ZTOZ-Zl-qnr - _ - / �� ~cr� ~^~^'^^---- ----'—~--------'— IN 46204 Ml lm tt-4 1639124134 woo 4 ,CITY OF CAPPML y y 92. 00 ni 0000 x Lw dRV IJ AUG 2 7 2012 oOO'a OCou689L/C 'Iuo9 NON sja ov:Go By A ST VINCENT CARMEL HOSPITAL T 4.� _ 13500 N NERI'_AN STREET kp wnawu .e R CARMEL,IN 96032- CYCLF 05/20/12 317 336-8035 0 Y E nwnrwl MAA» ►Anall w�c. wOt wOM rrld pwrt ywwA�o.oAn oArr i ww.rc 1 XXCITY OF CAR^Ei 16862061 mm—. - owl oacen+ora oERwce 1074 rol.oMUDE W.COVLOAW nr.coamoc mvwom c ►Aran CAYN MOSMTAL URVKZS COOP CWAPQ" M0.CO.M0.1 IRr,00.MO.A 'rH.CO.00.1 W%CO.M0.d um.y DETJlIL OF CURRENT CHARGES, PAIKENTS ANE ADCUST7,1U TS 05/if OOIDRJG SCREEN QU5020560C 91.00 91.00 05/1 001URINE DRUG SCR92006275 22.00 22.00 oF./lE 001ALCOHOL BREAT;;92005203 30.00 30.00 SAL NrE FORWARD 0.00 SU RY OF CURRENT CHARGES LABORATORY 91.00 91.00 EMERGENCY ROOM 52.00 52.00 SUB-TOTAL OF CUP.R. CHARGES 143.00 143.00 0 GU.R RELATION::HIP: S SEX F GUAR NO: 316862011 0 IF YOU HAVL INSURANCE YOUR BEN .SIT.°, ARE ASSIGNED TO US. TKAVI YOU FOR CHOOSTNG ST. VINCENT FOR YOUR FALTH CA E NEEDS. 0 T G T A L S 143.00 143.00 0 20! 4755409 PAY THI3 AMOUNT 0.00 0 ST VINCENT CAR*QEL HOSPITAL CAI MEL,IN D Q � AUG 2 7 2012 By 900'd OZ86689LIE LAOJ NON Sdd cv:60 ZTOZ-91-lnr L MQ$PITA �T vINCINT CAIWILL qo�PITA 2054373166 11-1-=777 I !sAt. - -t-�i I........ rr VINCEI;T CA ........... 11 A� ;3 ............... LE P2CWY 13500 N "TEP-10% ;207 FZLXAi"" C RIC XGO L L G 0 GB 6001AL1.......... e5r. ...... 74,+ 7055 CAtiMSL IN . . R.—I 10 10111 110111 31.13388095 t 0 1 10111 ....... ........ 4b al '00 80101 11011. 0300 AgORATORY,� V W1.M.if;ai w—,t4L 11 tn! 15�*=',..�;;;: X, F2;i.; YMM",' ax PAGE J. OF—1 CREATION 'A IL 511 •t. Y 1172 Qu WQXK COMP J I'M r. V .......... ST Hpf VINCENT LN oox ------------- ......... ......4.... 4804 AUG 2 7 2012 1 By TOO•d ozBecesLic NON S,4d 0t:60 ZTOZ-ZI-rinC Spelbring, James P - HR From: Snyder, Denise W Sent: Tuesday, July 31, 2012 9:10 AM To: Spelbring, James P - HR Subject: FW: Past Due Invoices What will it take to get these paid? -----Original Message----- From: Watkins, Gina fmailto:GMWATKIN(@stvincent.orgI Sent: Tuesday, July 31, 2012 9:02 AM To: Snyder, Denise W Subject: RE: Past Due Invoices I left him a voice mail message that he could pay the $55 which is what he said is the agreed amount. These were registered incorrectly and that is why the amounts are different. But I have left him a couple messages letting him know to pay the amount that was agreed on and I can make the adjustment on my end. I was told by Midwest Toxicology that they were not responsible for these bills. (per Charlotte) They never told me anything about not paying because of the amounts. I have been back and forth for months now on trying to get these claims paid. They are very old. Gina Watkins Reimburesment Specialist St. Vincent Health Patient Financial Services (317)583-3844 - Phone (317)583-3820 - Fax gmwatkin( stvincent.org -----Original Message----- From: Snyder, Denise W rmailto:dbristow(@carmel.in.gov1 Sent: Tuesday, July 31, 2012 8:59 AM To: Watkins, Gina Subject: Past Due Invoices Back on July 12th, I received several faxes from you regarding past due invoices, I forwarded these onto our HR Department attention Jim Spelbring. He contacted me via email on July 17th stating that the amounts on the invoices are incorrect which is why Midwest has not paid them. At that point he said that he had left you a few voicemails. Did you and he get this resolved? Denise Snyder Budget and Accreditation Manager Carmel Fire Department 317-571-2600 317-571-2615 - Fax dsnyder(@carmel.in.gov CONFIDENTIALITY NOTICE: 1 This email message and any accompanying data or files is confidential and may contain privileged information intended only for the named recipient(s) . If you are not the intended recipient(s), you are hereby notified that the dissemination, distribution, and or copying of this message is strictly prohibited. If you receive this message in error, or are not the named recipient(s), please notify the sender at the email address above, delete this email from your computer, and destroy any copies in any form immediately. Receipt by anyone other than the named recipient(s) is not a waiver of any attorney-client, work product, or other applicable privilege. 2 St. Vincent Hospital August 7, 2012 City of Carmel One Civic Square Carmel IN 46032 To Whom It May Concern: I:,.IV '.Ut•::O( Your employee :ame through our facility for a workers compensation accident.Citizens Management has been billed and has paid. However they have stated to us that the drug screening charges are not covered under workers comp insurance. 1 have enclosed a copy of this review and also a bill for you to submit payment for the services rendered. Please mail your payment to: ST. Vincent Carmel Hospital 6002 Reliable Parkway Chicago_I1 60686 If possible please return a copy of the bill with your payment and reference our account number 1079525258. Should you have any questions or need anything further,please feel free to contact me. A iin: :,`w Thank you for your time and attention regarding this matter. A CI'KSION "'`'"' Kris McEntee Workers Compensation Specialist 100330 N Meridian St. Suite li Indianapolis IN 46290 D 51.din.vnl 0—e.,lnt> 317-583-3897 V1}•nn•rallCd tn: tirn.icc•ot thrfour AUG 2 7 2012 :orn•n::.a•r n. .airl r... ENC: Copy of Charges By Rt•c�:'tnR` Copy of Explanation of Review. I..f II,v:I q;::iie:r.:a:I:•:c1ei P,' J iilo Integrity ;V!<;m.a Ice,1,a•A 1p. VY i.dum 'n•aticily .•d i:.tion nir.nn,c,Ihu•Inc•r.m,t ul ur m;ni.I,? 300•a lV101 • .1•YN. �T VINCEN.T.-HO.SP.- HEALTH tT..V.IN.C.ENT,. HOSP HEALTH 2001 W 86TH STREET.- 1207 REL.IAB.L.E...P.KWY.. .. acc,h n ;:; .........;;:c:: I au.,zt�(hfl ;;;;;,jrw�rNrer INDIANAPOLIS .IN-A.62.6.01� 0.2 CHICAGO. ll-.606.860012... �J17knENY,:NN11G.i':;' ;'d 'u�r+�lei+l�,eik�lritid,:`..:is 19 GMnMf! 11.1 BIX ...._. ,,:.. I 16 ...: .•.:.�.... .. ...... .1 gNC: ar.,..'P:Cyyfjr N°E� 7,:'. mtx. 04 b51112 ...... ....�.:..........: .... .,,...I...:n.. CITIZENS MANAGEMENT al,:::;x';:'vAU,c°o4[q:;:,;, p;;; vuuc°ooca::•.•..--...... AI I r.::...:...;... PO BOX 620 a.:..4. .............:.:.14 :00 ..... .........................;:..:. .. HOWELL, MI 48844 ° d 4lrLMM aDCCCn.11 w mCPCCr1-ATCfmM 8CCDC I$WN DATC �6 ucm LWG 4r1 CnAIfOL7 11NWgWCnCAOIMO[C a 02501"0450 PHARMACY.,.:.:.,_,....,....<..:. 05111 8 295 92 :.. ..:...: 2,0.,LABORATORY 86850 05111 1 51 00 •511:.1' :;:. �,......0..,LABORATORY... '':::'.::�.;":8,59.00-..:.:r:::-:..:..,::..,:',;:;0 .........:.... .......:.�:..:r-:�1:'7;�:.:pp':' :r:::;:::�.......17 00.0 LABORATORY 86901 05111 1 0521:1: :::::::`,.. . ::: ::..::. ;:�- 48.::,..,; .:.:,.... . .. ..... . :.:. .........1 LAB CHEMISTRY 05111 243 00.,,, "i'i:i.;:; .. 165::;5 LAB/HEMATOLOGY 8502,5,.,,,, 05111 1 129 00 5,.LAB/:HEMATO.LO.GY 5 LAB/HEMATOLOGY 8,57'.3,01. 05111 1 .30.:`.f?X. X4 dX X—RAY/CHEST 71010 05111 1 220 00..I 1..: . ., :HEAD•............ °. :..�.:, . .. '1 725;�::01 •70498 05111 1 0 EMERGENCY. ::ROOM'::: ., .10 EMERGENCY ROOM 05111 1 1980 00 1:1 : x:b4: :..........:.30:. :::0:0: 0836 5 :.ORUGS/D.��Ax:L::C:OD�-:.:,::.,..•,.. ,.. ,.... :Q.996::7;;::;.::.::.:::.::::::::.,:.:::°:03 :., .........,: .:,.:. .................::;:.'. 0636 ,RUGS,/DETAIL CODE 90715 05111 1 167 14 ' :...:...:.::.:::...:..... ....,.,.....,..:...... ........... : g A 1 I PAGE_ OF CREA710NDATE 2112 • 4 ' w�Cu Ae L1Ra ialz*t+aeroG::::::::'W.R9!,:. .. .nr'oU5"; 1 60 :;:';�:',�'::':':,�i�liwo..�.'.nn!�. WORK COMP ........... Y Y 11334 0 -PD 1 _ --- ---- :....:.. . . ......... �° ^.'. 'i•noauAidlr%LEiiiMG,�iVlll16FR:: I ..... ....:.. 1 87349 :9130'. d92300 9S909 311.: "305' l""IuY"�' 87349 i . .. E92 1 �. e: F.:......: katm+ouio:_ R 1 08321 ..A.:...:.... ....,..... , :,...666c ,.. ,�....,... 3060 _ --^wj COLLINS PIMP MARK ,ART nr1,p°epdne...:;1;:?:, r1,QPrWtTwt1:: Fl 1982770285 anli: CHAVIS wr FI DION pq.. ..... u°+ � E�1S MANAGEMENT ' ,a K fl 282N000OOX Rar LAX .._... .OX 620 ..D. RD 8 A� LAC7 ............... ..d.•:.:,.,,.,:••.,..::.,..•,.>•..:......a. ..u.......... IMY CtH l l P ..h,AY nl.. NOWE1.1. M� �ru� ZZ OZ-9�—LJC1`d 7 F Yr C� EXPLANATION OF BENEFIT Date Processed:07/0512012 WORKERS'COMPENSATION HEALTH CARE SERVICES Service Company:Citizens Mangement Inc. Telephone Number:(800)533-9366 f Carrier Name:CITY OF CARMEL Claim Number:0385-12-03352 Address:P.O.BOX 620 NAIC/Self Insured Number: HOWELL, MI 48844-0620 Employer:CITY OF CARMEL Policy#:0385-12 Employee Name: <; Provider Name:ST VINCENT HOSPITAL HEALTH Address: y Address:1207 RELIABLE PARKWAY CHICAGO, IL 60686 "Social Security/FEIN- NPI/FEIN:1306898960/35-0869066 Date Of Injury.05/11/2012 patient Account#:1079525258 Date on Provider Bill:05/2112012 PPO:IWC Date Bill Received by Carrier:06/04/2012 v; ST VINCENT HOSPITAL HEALTH 1207 RELIABLE PARKWAY THIS IS NOT A BILL CHICAGO, IL 60686 fi pate Of r Service Reviewed Billed Code Rev Code Service Description Diagnosis Units Billed Allowance" Explanation 05/14!12 250 PHARMACY GENERAL 873.49 8 295.92 260.41 , 05111/12 272 STERILE SUPPLY 873.49 3 84.00 73.92 05/11/12 86850 300 ANTIBODY SCREEN RBC 873.49 1 51.00 44.88 ty r 05/11/12 86900 300 BLOOD TYPING 873.49 1 17.00 0.00 206 05/11/12 86901 300 BLOOD TYPING 873.49 1 17.00 0.00 206 �I' 0 301 OLIC 873.49 1 074 05/11/12 82055 301 ALCOHOL 873.49 1 243.00 0.00 972 { Q 605 301 LACTATE 873. 1 165.00 145.20 05/11/12 85025 305 BLOOD COUNT 873.49 1 129.00 108.78 974 05/11/12 85610 305 PROTHROMBIN TIME 873.49 1 84.00 70.56 974 . F 05/11/12 85730 305 THROMBOPLASTIN TIME 873.49 1 112.00 98.56 974 05/11/12 73030 320 EXAM SHOULDER 873.49 1 315.00 277.20 } 05/11/12 71010 324 EXAM CHEST 873.49 1 220.00 193.60 * ' z 05/11/12 70486 351 CAT MAXILLOFACIAL 873.49 1 1,725.00 1,518.00 974 r 05/11/12 70498 351 ANGIOGRAPHY NECK 873.49 1 3,028.00 2,664.64 •,. * t 05/11/12 12011 450 REPAIR OF WOUND 873.49 1 2,505.00 445.44 974 05/11/12 99284 450 ER DPT VISIT HIGH 873.49 1 1,980.00 1,494.09 974 25 05/11/12 Q9967 636 LOCM 300-399MG 873.49 100 30.00 0.00 217 ' 05/11/12 90715 636 VACCINE DTP 873.49 1 167.14 3.76 m nF TAr 14 AN\ID RE a A,ll\I -_-----Snials�_1��34_(]F_-__7_545..9-7_--.----------..�_.--•--- EXPLANATION OF BENEFIT Date Processed:07/05/2012 WORKERS'COMPENSATION HEALTH CARE SERVICES Service Company:Citizens Mangement Inc. Telephone Number:(800)533-9366 Carrier Name:CITY OF CARMEL Claim Number:0385-12-03352 Address:P.O.BOX 620 NAIC/Self Insured Number: HOWELL,MI 48844-0620 Employer:CITY OF CARMEL Policy#:0385-12 Employee Name Provider Name:ST VINCENT HOSPITAL HEALTH Address Address:1207 RELIABLE PARKWAY CHICAGO,IL 60686 *Social Security/FEIN: *NPI/FEIN:13068989601 35-0869066 Date Of Injury:05111/2012 Patient Account#:1079525258 Date on Provider Bill:05/21/2012 PPO:IWC Date Bill Received by Carrier:06/04/2012 ST VINCENT HOSPITAL HEALTH 1207 RELIABLE PARKWAY THIS IS NOT A BILL CHICAGO,IL 60586 Reason Codes: 206 ADDITIONAL DOCUMENTATION IS NEEDED TO CLARIFY MEDICAL NECESSITY FORTHIS PROCEDURE. 217 THE VALUE OF THIS PROCEDURE IS INCLUDED IN THE VALUE OF ANOTHER PROCEDURE PERFORMED ON THIS DATE. 972 THIS IS NOT RELATED TO THE INJURY AND IS DENIED. 974 P RE REPRICE ING TO TH IX/FH RV BENCHMARK OUTPATIENTFACILITY DATABASE BASED ON THE PROVIDER'S GEOGRAPHIC AREA. UNLESS OTHERWISE NOTED,ALL REDUCTIONS ARE DUE TO CHARGES EXCEEDING THE OFFICIAL MEDICAL FEE SCHEDULE Provider: IF YOU INTEND TO SEEK RECONSIDERATION,PLEASE CONTACT THE CARRIER INDICATED ABOVE WITHIN OD CALENDAR DAYS OF RECEIPT OF THIS NOTICE. IF ADDITIONAL INFORMATION IS REQUESTED,PLEASE FORWARD THE INFORMATION TO THE CARRIER Employee: FOR INFORMATION ONLY THIS IS NOT A BILL.IF YOU ARE BILLED FOR ANY SERVICES RELATED TO THIS WORKERS'COMPENSATION CLAIM,DO NOT PAY. DO CALL THE CARRIER LISTED ABOVE. 'PROTECTED INFORMATION TO BE USED FOR INDENTIFICATION PURPOSES ST VINCENT HOSPITAL HEALTH 1207 RELIABLE PARKWAY CHICAGO,IL 60686 a 0 0 m m DETACH AND RETAIN TOP SECTION FOR YOUR RECORDS NON t. i NEGOTIABLE COPY 1292774-2 tell IFT1, T owl oir"' U6 Ilium , w*rt 1 % . . Spelbring, James P - HR From: Strickling, Krisinda [KLSTRICK @stvincent.org] Sent: Thursday, August 16, 2012 10:32 AM To: HR Subject: Discount for med bills Here is the discount(25%) I agreed to give Cannel for the ding testing done at St Vincent 86"St Ior tlic lollowiug employees. i�`2�459$`?Si seen 5/11/2012, Drug testing is$243.00 with discount Carmel will pay$183.00 1 o ,25g seen 5/18/2012, Drug(csing is$243.00 with discount C:u-mel will pay x;183.00 Plcase remit payment within 30 days of receipt of this electronic letter. 'Thank you. Kris Strickling Workers Compensation Reimbursement Specialist St Vincent Health System P)317-583-3897 F)317-583-3820 klstrick@stvincent atrg "Until One has Loved an Animal, part of their soul remains UNAWAKENED" CONFIDENTIALITY NOTICE: This email message and any accompanying data or files is confidential and may contain privileged information intended only for the named recipient(s). If you are not the intended recipient(s), you are hereby notified that the dissemination, distribution, and or copying of this message is strictly prohibited. If you receive this message in error, or are not the named recipient(s), please notify the sender at the email address above, delete this email from your computer, and destroy any copies in any form immediately. Receipt by anyone pvilege other than the named recipient(s) is not a waiver of any attorney-client, work product, or uq- St.Vinccnt St. Vincent Hospital August 7, 2012 City of Carmel One Civic Square Carmel IN 46032 To Whom It May Concern: P.C.I,—i yi*r. Your employee game through our facility for a workers compensation accident. Citizens Management has been billed and has paid. However they have stated to us that the drug .. screening charges are not covered under workers comp insurance. I have enclosed a copy of this review and also a bill for you to submit payment for the services rendered. Please mail your payment to: ST.Vincent Carmel Hospital 6002 Reliable Parkway Chicago_Il 60686 - -. If possible please return a copy of the bill with your payment and reference our account number 1079598751. Should you have any questions or need anything further,please feel free to contact me. Thank you for your time and attention regarding this matter. iCENSION " Kris McEntee Workers Compensation Specialist 100330 N Meridian St. Suite 200 N D G=1� Indianapolis IN 46290 317-583-3997 AUG 2 7 2012 i ,allcd cn: C of the roof By "l ENC: Copy of Charges lice Copy of Explanation of Review. r ,n � f • .. :ia PAI � �•. �T.__V.I.NC.ENT. HO.S.P____HEALTH_.. .....ST.__VINCENT...HOSP .... HEALTH CNTL^ b.MEC 200.1...W .86TH.,.STREET....._ 1207......RELIABLE PKWY REC.v 1UMIFNT GCNrRSPEROH 7 LNOIANAPOLIS ,..LN.....462.6019.02, _CH.ICAGO. IL__.6.068600.12 - 1.6.rnxNO. _....... � ---rQn y pdi=NT NAA1F -... c rnnENl nDCRESS ---a'I 1�1 0 DIHTHDnTE 11 SEX ADMISSION: ::161N1H 17„IN GO\DriIIXJ CODES _^ACUi 3C :12 DATE - 13 HR 10 TYPE tj$RC. 1° 13 2C: 21 -:22 23 G1 IIHHR16f-. 7:z. �, T•l- :(XCIIRRr.NCF 0 IRRENU..SPAN 96 Or:f%1RRCNCE^PAN 97 CODE'^ DATE -\ • CODE -UNE 0'- 'CODE ''FROM THROUGH: COME FROM 04 51812 CITIZENS MANAGMENT C v4 AMOUNT �• RT •• vzcuECODCs COCE�� AIAOUNT • °� '��'I' :CODE 'AMOUNT :�� ' PO BOX 620 a 4 11 00 b HOWELL, MI 48844 C d <2 REV GD y3 DCSCRF,TIGy.I uHCfCS/PATE I'r,Ir?S CODE SERV OATE 't;rPV..UN':TS OT TOTAL CI-ROES OB N-1-COVEREDOI.AP-- 09 0250 PHARMACY 2 3 . 58 86 b3 Qon LAB.ORATOR'Y, 86850 05181 1 < 51 00 030,0 LABORATORY 86900 05181 1 17 00.. 03.00 LABORATORY 86901 05181 1 17 00! 50 CHEMISTRY 800,48 05181 1 166 00 ° 0301 LAB%CHEMISTRY 820.55 81 030 AB HEMA 0 GY _ . 8502 05181 1 129 00 °032'b DX X RAY' 73,030 05181 l 315 00! ° °0320 DX...._X—RAY___ 73510 05181 1 293 00 0320 OX:. X RAY ! 73610 05181 1 316 LOO "045..0_ EMERGENCY ROOM 9928525 05181 1_ 2.6.65 00. " 12 G 1° IB 2 t° ]1 0001 PAGES OF CREATION DATE 052412 ° 4270- 861 ERr... :.. .....:..__........................_ ,. ..... ...,. 89 6 0 50 PAY St HEAL7HPL A .. "WORK COMP._.. Y Y. 4270 8 57 DIHFH ,RV ID C cOPREL 601N$URED'S UNIQUE ID 58'W$URE7$NPIJ,E:::; ., .: .... .-::. .. �: 18 313860990 ° s D :. .:. :: 9 :.. C 63TRE4TMENr aU_:iORIZATIIXJ CODES �El DCCUMEr1T:CONROI NUMB ER 65 EIJ PLOVER NAr1E;: :: - 92300 9190 4019` b 6d ADM IT 'rV PATIEM 9592' 71 r.C1Cf FCI'.. E88 _9 73 nk::: IIEASbN ux 70 PRIIICIPAL':PROCEDURE'.; - ,r,: _frHER PRCY-VDU P.E 'S 'e ATTF1.OiNG: -NH C(1PL ...::::GOD_ DATE DATE ':..°•:.. 1i. b JCDE "-: '::DATE .. 1902992019 L'A' TIGCHELAAR FIRST MATTHEW d OTHER:PROCEDJ Rc :DATE .-.,. ,v .1-.>.•- .- L.AS7, FIRST @-TA ENS MANAGMENT O1COB3282NOOOOOX 750THEH NH c'N ... ... ............. ...... PO BOX 620 LA-I S FIRST 'ie 6TH ER NF QUA: HOWELL, MI 48844 ^T FIRST 't W>R11VED O`AR NO. 1 HF.CFNI IF ICAI I(TJ::ON 1 H E Ii nVF R$F APP..Y 10 1HIS H.IIA.AN ARE VAUF A FAIT HFN FOF. NUB S�'d1' 6EEMRG01' EXPLANATION OF BENEFIT Date Processed:07/06/2012 WORKERS'COMPENSATION HEALTH CARE SERVICES Service Company:Citizens Mangement Inc. Telephone Number:(800)533-9366 Carrier Name:CITY OF CARMEL Claim Number:0385-12-03545 Address:P.O. BOX 620 NAIC/Self Insured Number: HOWELL, MI 48844-0620 Employer:(-'N OF CARMEL Policy#:0385-12 Employee Name: Provider Name:ST VINCENT HOSPITAL HEALTH Addres,,- Address:1207 RELIABLE PARKWAY CHICAGO, IL 60686 *Social Security/FEIN: *NPI/FEIN:1306898960/35-0869066 Date Of Injury:05/18/2012 Patient Account#:1079598751 Date on Provider Bill:05/24/2012 PPO:IWC Date Bill Received by Carrier: 06/14/2012 ST VINCENT HOSPITAL HEALTH 1207 RELIABLE PARKWAY THIS IS NOT A BILL CHICAGO, IL 60686 Date Of Service Reviewed Billed Code Rev Code Service Description Diagnosis Units Billed Allowance"* Explanation 05/18/12 250 PHARMACY GENERAL 923.00 3 58.86 51.80 05/18/12 86850 300 ANTIBODY SCREEN RBC 923.00 1 51.00 44.88 05/18/12 86900 300 BLOOD TYPING 923.00 1 17.00 0.00 206 05/18/12 86901 300 BLOOD TYPING 923.00 1 17.00 0.00 206 05/18/12 80048 301 BASIC METABOLIC 923.00 1 166.00 146.08 074 05/18/12 82055 301 ALCOHOL 923.00 1 243.00 0.00 972 05/18/12 85025 305 BLOOD COUNT 923.00 1 129.00 108.78 974 05/18/12 73030 320 EXAM SHOULDER 923.00 1 315.00 277.20 05/18/12 73510 320 EXAM HIP COMPLETE 923.00 1 293.00 257.84 05/18/12 73610 320 EXAM ANKLE COMPLETE 923.00 1 316.00 278.08 05/18/12 99284 450 ER DPT VISIT HIGH 923.00 1 2,665.00 1,494.09 161 974 25 Totals: 4,270.86 2,658.75 A O O DET-'NCH AND RETAIN TOP SECTION FOR YOUR RECORDS I EXPLANATION OF BENEFIT Date Processed:07/06/2012 WORKERS'COMPENSATION HEALTH CARE SERVICES Service Company:Citizens Mangement Inc. Telephone Number:(800)533-9366 Carrier Name:CITY OF CARMEL Claim Number:0385-12-03545 Address:P.O.BOX 620 NAIC/Self Insured Number: HOWELL,MI 48844-0620 Employer:CITY OF CARMEL Policy#:0385-12 Employee Nam Provider Name:ST VINCENT HOSPITAL HEALTH Addres Address:12D7 RELIABLE PARKWAY CHICAGO,IL 60686 *Social Security/FEIN *NPI/FEIN:1306898960/35-0869066 Date Of Injury:05/18/2012 Patient Account#:1079598751 Date on Provider Bill:0512412012 PPO:IWC Date Bill Received by Carrier:0611412012 ST VINCENT HOSPITAL HEALTH 1207 RELIABLE PARKWAY THIS IS NOT A BILL CHICAGO, IL 60686 Reason Codes: 161 BASED ON THE AVAILABLE INFORMATION,THE SERVICES RENDERED APPEAR TO BEBEST DESCRIBED BY THIS CODE. 206 ADD;T)ONAL DOCUMENTATION IS NEEDED TO CLARIFY MEDICAL NECESSITY FORTHIS PROCEDURE. g72 S IS NOT RELATED TO THE INJURY AND IS DENT 974 PROCEDURE REPRICED ACCORDING TO THE INGENIX/FH RV BENCHMARK OUTPATIENTFACILITY DATABASE BASED ON THE PROVIDER'S GEOGRAPHIC AREA. UNLESS OTHERWISE NOTED,ALL REDUCTIONS ARE DUE TO CHARGES EXCEEDING THE OFFICIAL MEDICAL FEE SCHEDULE Provider: IF YOU INTEND TO SEEK RECONSIDERATION,PLEASE CONTACT THE CARRIER INDICATED ABOVE WITHIN GD CALENDAR DAYS OF RECEIPT OF THIS NOTICE. I F A DDITIONAL INFORMATI ON IS REQUESTED,PLEASE FORWARD THE INFORMATION TO THE CARRIER Employee: FOR INFORMATION ONLY THIS IS NOT A BILL IF YOU ARE BILLED FOR ANY SERVICES RELATED TO THIS WORKERS'COMPENSATION CLAIM,DO NOT PAY. DO CALL THE CARRIER LISTED ABOVE. "PROTECTED INFORMATION TO BE USED FOR INDENTIFICATION PURPOSES ST VINCENT HOSPITAL HEALTH 1207 RELIABLE PARKWAY CHICAGO,IL 60686 v DETACM AND RETAIN TOP SEC 1 IOM FOR YOUR RECORDS OPT NON NEG" OTIABLE C i 1292985-2 Spelbring, James P - HR From: Strickling, Krisinda [KLSTRICK @stvincent.orgj Sent: Thursday, August 16, 2012 10:32 AM To: HR Subject: Discount for med bills Here is the discount (25(3'()) I agreed to give Guuiel for the chug testing done at St Vincent 86"'St for the following employees. seen 5/11/2012, Drug testing is $243.00 with discount Carmel will pay$183.00 seen 5/18/2012, Drug tesing is $243.00 wgth discount Carmel will pay$183.00 Please remit payment within 30 clays of receipt of this electronic letter. "Thank you. Kris Strickling Workers Compensation Reimbursement Specialist St Vincent Health System P)317-583-3897 F)317-583-3820 k1strick0stvincent.or g "Until One has Loved an Animal, part of their soul remains UNAWAKENED" CONFIDENTIALITY NOTICE: This email message and any accompanying data or files is confidential and may contain privileged information intended only for the named recipient(s). If you are not the intended recipient(s), you are hereby notified that the dissemination, distribution, and or copying of this message is strictly prohibited. If you receive this message in error, or are not the named recipient(s), please notify the sender at the email address above, delete this email from your computer, and destroy any copies in any form immediately. Receipt by anyone other than the named recipient(s) is not a waiver of any attorney-client, work product, or other applicable privilege. 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 Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s)or bill(s)) 11/01/11 11.01.11 $55.00 11/26/11 11.26.11 $55.00 12/28/11 12.28.11 $55.00 01/16/12 01.16.12 $55.00 01/16/12 01.16.12 $55.00 05/11/12 1079598751 $183.00 05/18/12 1079525258 $183.00 05/20/12 05.20.12 $55.00 1 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 St. Vincent Carmel Hospital IN SUM OF $ 13500 N. Meridian Street Carmel, IN 46032-1456 $696.00 ON ACCOUNT OF APPROPRIATION FOR Carmel* HR Department PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members Prior Year I hereby certify that the attached invoice(s), or 1201 11.01.11 43-588.00 $55.00 Prior Year bill(s) is (are)true and correct and that the 1201 11.26.11 43-588.00 $55.00 Prior Year materials or services itemized thereon for 1201 12.28.11 43-588.00 $55.00 which charge is made were ordered and 1201 01.16.12 43-588.00 $55.00 received except 1201 01.16.12 43-588.00 $55.00 1201 1079598751 43-588.00 $183.00 1201 1079525258 43-588.00 $183.00 Monday, August 27, 2012 1201 05.20.12 43-588.00 $55.00 Director, HR Title Cost distribution ledger classification if claim paid motor vehicle highway fund