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214265 11/07/2012 CITY OF CARMEL, INDIANA VENDOR: 362339 Page 1 of 1 0 ONE CIVIC SQUARE CITIZEN MANAGEMENT INC CARMEL, INDIANA 46032 ATTN:JUDY THEIBERT CHECK AMOUNT: $750.00 o� PO BOX 620 CHECK NUMBER: 214265 HOWELL MI 48844-0620 CHECK DATE: 1117/2012 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1205 4347500 10 . 17 . 12 750 . 00 CLAIMS HANDLING CMI PO Box 620 Self-Insurance Howell, MI 48844-0620 1-800-533-9366 x 3276 BILLING NOTICE Steve Engelking Date: October 17, 2012 City of Carmel One Civic Square Reference: City of Carmel Carmel, MI 46032 Self-Insured Workers' Compensation Loss Fund Remarks: Claims Handling Excess Premium Policy Period: 01-01-11 to 12-31-11 Service Fee Billing Period: 07-01-12 to 09-30-12 Other $750.00"r_ (See Comments): _ s Comments: The back-up documentation is attached. Please submit payment to the,,addre s`above Attn: Judy Theibert F -,`� r 3 I CM1 _ Electronic Banking Information D z/ Wells Fargo Bank, N.A. Summit, NJ '-' -\A Account Name: Fox Hill Holdings, Inc. Depository Account Acct: 2000039122915 ACH Routing#: 021200025 NOV 0 C C 2012 Wire Routing#: 121000248 SWIFT ID#:WFBIUS6S By Total Amount Due: $750.00 By: November 28, 2012 PLEASE RETURN COPY WITH YOUR PAYMENT CityOfCarmel-CH-1012 10-17-12ICB ClientBill{SIW-3(2-91) UM1 A YORK RISK SERVICES COMPANY October 17, 2012 Steve Engelking City of Carmel One Civic Square Carmel, IN 46032 Dear Mr. Engelking: Enclosed you should find an invoice for the claims handling of policy period January 1, 2011 through December 31, 2011, billing period July 1, 2012 through September 30, 2012. The back-up documentation is attached. Please feel free to give us a call if you have any questions. Thank you, Cassey Brooks Risk Management Services CMI 800-533-9366 x3279 cassandra.brooksacmi- oLrkrsg com Enclosures Third Party Administration • Risk Management• Loss Control Services 645 W. Grand River Ave,Suite 100• Howell, MI 48843 0 PO Box 620 Howell, MI 48844-0620 Phone 1 800 - 533 -9366 Fax 1 517- 548 9246 www. cmi - yorkrsg . com Citizens Management Inc Workers' Compensation Claim Handling Report Summary City of Carmel Policy Period: 01/01/2011 Thru 12/31/2011 Billing Period: 07/01/2012 Thru 09/30/2012 ------------------------------------------------------------------------ Claimant Type Desc:Indemnity Claimant 1 x —1 Claimant Type Desc:Medical Claimant 0 Claimant Type Desc:Transferred To Indemnity Claimant 0 Grand Total: 1 Run Date:10117/2012 11:06:51 Run By:CXB City of Carmel-Confidential Page 1 of 1 ' � Citizens Management Inc Workers'Compensation Claim Handling Report Indemnity Claim Listing City OfCarmel Policy Period: 01101/2011 Txm12/31u011 Billing Period: 07m1o012 Txm09m0/2012 ________________________________________________________________________ Claim Claimant Entry Date Date mInjury ________________________________________________________________________ Claimant Type oeso:Indemnity 0385-11'12616 Hu|oo.mam 09/18/2012 08m1s011 mo/mxm 1 Run Date: 10/17/2012 11:07:26 Run By:CXB City of Carmel-Confidential Page 1 of 3 ' ' . ��;�;� Management n~u��0 �vx��" onc � Workers'Compensation Claim Handling Report Medical Claim Listing City of Carmel Policy Period: 01m1m011 Txm 12m1o011 Billing Period: 07/01c012 Txm09/30/2012 ________________________________________________________________________ Claim Claimant Entry Date Date mInjury ------------------------------------------------------------------------ cumonr»nuouncmemca Claimant n Run Date: 1un7oo1x11z7on Run By:cxo City of Carmel connummu| Page umn Citizens Management Inc Workers'Compensation Claim Handling Report Transferred To Indemnity Claim Listing City of Carmel Policy Period: 01/01/2011 Thru 12/31/2011 Billing Period: 07/01/2012 Thru 09/30/2012 ------------------------------------------------------------------------ Claim Claimant Entry Date Date of Injury ------------------------------------------------------------------------ Claimant Type Desc:Transferred To Indemnity Claimant 0 Grand Total: 1 Run Date:1011712012 11:07:26 Run By:CXB City of Carmel-Confidential Page 3 of 3 Spelbring, James P - HR From: Spelbring, James E-CFD Sent: Friday, October 26, 2012 4:20 PM To: Spelbring, James P- HR Subject: FW: City of Carmel -Claims fee billing for new claim. From: Becker, Paul [mailto:Paul.Becker @cmi-yorkrsg.coml Sent: Friday, October 26, 2012 3:23 PM To: Spelbring, James E - CFD Cc: Brooks, Cassandra; Engelking, Steve C; mike.wells @hylant.com; Williamson, Elden; Dubin, Matthew Subject: City of Carmel - Claims fee billing for new claim. Jim, Good afternoon. I'm following up on a call you made to Ms. Cassey Brooks in our Howell Risk Management Dept. You had called about a newly reported claim for a Mr. Mark Hulett. Cl. # 0385-11-12616. Date entered into our claims system was 9-18-12, and the date of loss was 8-1-2011. A little background. Your claims administration contract with CMI, is on a 'per claim' basis. There are Medical only claims and there are Lost time (including litigated and or more involved claims) . The service contract claims management fee is adjusted 6 months following each contract term, and periodically thereafter, if a new claims arises, or if a medical only claim transfers to a lost time claim. This claim was reported to us shortly after we processed a refund (of $2,810) for the 1-1-11 to 12-31-11 contract term back in July 2012. An email (7-26) was sent to Barb and Steve, providing advance notice of this pending refund. This claim having been reported to us in Sept. 2012, missed this adjustment. Thus the billing for the $750 now for Mr. Hulett's claim. Even though the claim is being denied (on your behalf), by our experienced claims adjuster - Elden, our services are essential to provide for a proper denial (for the claimant, you, and the State of Indiana) . Claims situations like this require that we use our Sr. Lost Time Adjuster Elden Williamson, to properly manage and monitor this claim. Thus the charge for Lost time claims vs. a Medical only claim. I had Elden provide me with a summary of the services he has provided on the denial of this claim on behalf of the City. From Elden Williamson: On this claim, I completed the following: i - Received contact from aim Spelbring advising on new claim being filed with alleged d/o/l over lyr prior; - Completed and sent Medical Release form and Physician/Provider list to be signed & completed by clmt; - Responded to inquiry from Denise Snyder/Mgr @ Carmel Fire Dept. on why surgery not authorized immediately; - Made multiple calls to attempt to reach clmt - (2) calls; - Phoned and spoke w/ Denise Snyder/Mgr w/ Carmel Fire Dept and gave her message to have clmt call me back; - Reviewed ISO Claim Search recording (6) prior insurance claims for this clmt; - Received call back from clmt and completed clmt interview; - Provided verbal explanation for claim decision and denial to clmt; - Completed formal denial letter to clmt, w/ cc to City; - Completed and filed required IND53914 Denial Notice w/ Indiana Worker's Compensation Board, w/ cc to clmt, and the city ; - Diaried file to monitor for notice of representation or litigation to contest denial, as clmt not happy w/ denial. I posted Plan of Action to proceed with file closure 11/19/2012, if we have not received any notice that the denial is being contested within 30 days Jim, we take the denial of particular claim seriously, and we strive to manage it properly from the start. Our services are fully at work with regards to a denied claim or an active claim. If you should have any further questions regarding this matter, please feel free to call me. Have a great Friday and weekend. Regards, Paul AgE • C M1 4�..�t Paul Becker, MBA, ARM, ALCM I Senior Account Executive CMI,A York Risk Services Company (616)258.7730 Direct/effective 10-30-12 616.222.3961 4100 Embassy Drive SE Grand Rapids, MI 49546 Cell: 616.446.2261 Efax: 517.338.5091 Pau1.becker @cmi-yorkrse.com This e-mail,including attachments, is intended for the exclusive use of the addressee and may contain proprietary,confidential or privileged information. If you are not the intended recipient,any dissemination, use,distribution or copying is strictly prohibited. If you have received this e-mail in error, please notify me via return e-mail and permanently delete the original and destroy all copies. 2 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)) 10/17/12 10.17.12 Claims Handling $750.00 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 Citizens Management Inc. IN SUM OF $ PO Box 620 Howell, MI 48844-0620 $750.00 ON ACCOUNT OF APPROPRIATION FOR Administration Department PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members 1205 10.17.12 43-475.00 $750.00 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 Monday, November 05, 2012 Director, Administration Title Cost distribution ledger classification if claim paid motor vehicle highway fund