212894 09/25/2012 CITY OF CARMEL, INDIANA VENDOR: 366535 Page 1 of 1
ONE CIVIC SQUARE ACCENT CHECK AMOUNT: $384.06
CARMEL, INDIANA 46032 PO BOX 952366
ST LOUIS MO 63195-2366 CHECK NUMBER: 212894
CHECK DATE: 9125/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 384 . 06 OTHER EXPENSES
Dept 19425
PO Box 1259
Oaks, PA 19456
PLEASE DO NOT IIII I I IIIIIIIII I III III�I MAIL PAYMENTS TO
I I III IIIIII S ADDRESS
k((fA or
Correspondence Address:
August 08, 2012 7171 Mercy Road
PO BOX 69004
Omaha, NE 68106-5004
I.IIIII�IIII�I11111�� I�IIIIIII � � 111�11��1111 „I11�111111 88586-506 Phone: 888-633-5516
CARMEL FIRE DEPT Nebraska: 402-384-5100
2 CARMEL CIVIC SQ TTY Phone: 800-833-7352
CARMEL, IN 46032-2584
ACCOUNT NUMBER: 13 0758 8256882
Re: Request for refund of overpayment. (Tin#: 356000972)
Accent Cost Containment Solutions ("Accent") has been enlisted by CIGNA HEALTHCARE PROCLAIM to recover the amount
indicated below.
We respectfully request your remittance in full, payable to either Accent or to the above mentioned client. Please send the
refund or contact our office within 30 days of the date of this letter.
For questions about this request, contact our office directly or submit your inquiry in writing to the correspondence address
indicated above.
Respectfully, n,/
l�(/C?�
SAMANTHA WEGNER
Recovery Specialist
Accent
1-888-633-5516 ext. 00000
Business Hours- CST:
Monday- Thursday 7:00 a.m. to 5:00 p.m.
Friday 7:00 a.m. to 3:45 p.m.
The overpayment identified is for the below customer and correlates to the following claim(s):
Amount Due: $384.06
Reason: billing error - late credit
Customer Name: LISA M JONES
Date(s) of Service: 04/14/2012
Total Charges: $384.06
Total Paid: $384.06
Plan Participant: LISA M JONES
Patient Number: 201201237
See Reverse for Calculations
506-88586-DOCOPI TEAR ALONG LING AND RETURN LOWER PORTION WITH PAYMENT
Account Number: 13 0758 8256882
Actual:
Claim Account Date of Procedure Charge Allowed Customer Benefit Check Check
Number Number Service Code Liability Number Issue
Date
96512136- 201201237 04-14-2012 $384.06 $0.00 $0.00 $384.06 282318315 05-23-2012
905360001 to 04-14-2012
Total $384.06 $0.00 $0.00 $384.06
Recalculated:
Claim Account Date of Procedure Charge Allowed Customer Benefit Check Check
Number Number Service Code Liability Number Issue
Date
96512136- 201201237 04-14-2012 $0.00 $0.00 $0.00 $0.00 282318315 05-23-2012
905360001 to 04-14-2012
Total $0.00 $0.00 $0.00 $0.00
Date: 09/24/2012
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-7543
(317)571-2604 FederalID# 356000972
ACCOUNT MST®RY
Bill To: LISA M JONES ICD-9: 95919 E8859
1002 W 35TH STREET
INDIANAPOLIS, IN 46208-
From: 1289 W CITY CENTER DR
To: IU HEALTH NORTH
LIBRTY MUTUAU7203
Patient: LISA JONES WC80DA50583
1002 W 35TH STREET Insurance
INDIANAPOLIS, IN 46208- 2
Patient No: 201201237
CONTACT LIBERTY MUTUAL 800-500-7044 STATUS OF CLAIM
Total Amount Total Paid Balance
$384.06 $384.06 $0.00
D"ate har
Qescr:IptLOn CPT Cges Credits
04/14/2012 BASIC LIFE SUPP-EMERGENCY A0429 $375. 00
04/14/2012 MILEAGE A0425 $9.06
06/06/2012 COMMERCIAL INSURANCE PAYMENT (; (C� 11 CD(,OgZgt J $384 . 06
06/14/2012 COMMERCIAL INSURANCE PAYMENT JJ tl�l�� ' �� $384. 06
09/24/2012 REFUND $-384.06
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
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
DEPT.# INVOICE NO. ACCT#!TITLE AMOUNT 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
SEP 2 4 2012
0
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund