HomeMy WebLinkAbout216622 01/29/2013 - .f CITY OF CARMEL, INDIANA VENDOR: T359686 Page 1 of 1
ONE CIVIC SQUARE ANTHEM BLUE CROSS BLUE SHIELD
` CARMEL INDIANA 46032 PO BOX 105557 CHECK AMOUNT: $399.92
,
'w �c ATLANTA GA 30348-5557 CHECK NUMBER: 216622
CHECK DATE: 1/29/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 399 . 92 OTHER EXPENSES
CIO ` EL
JAAZEs BRAIN_ARD, MAYOR
January 24, 2013
Anthem Blue Cross Blue Shield
P.O. BOX 105557
Atlanta, GA 30348-5557
RE : Laxma Gudoor claim ID 2012359QA6395 DOS 11/29/2012
Dear Sir/Madam:
Enclosed you will find refund check in the amount of$399.92.
This account has been paid in full as January 17, 2013 payment received
from Auto Insurance AAA check # 034217 for $399.92.
Auto is Primary refunding Health Insurance over payment $399.92.
If you have any questions, please feel free to contact me at (317) 571-2604.
Sincerely,
Alaw
Michelle T. Harrington
Billing Administrator
CARMEL FIRE DEPARTMENT
STEVEN A. Cours HEADQUARTERS
TWO CIVIC SQUARE, CARNIEL, INr 46032 OFFICE 317.571.2600, FAx 317.571.2615
Date: 01/24/2013
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-7543
(317)571-2604 Federal lD# 356000972 l�T RTr V
ACCOUNT IMST®� ]L
Bill To: LAXMA GUDOOR ICD-9: 78650 7231 E8130
11852 BOOTHBAY LANE
FISHERS, IN 46037-
From: 9800 N MERIDIAN ST
To: ST. VINCENTS HOSPITAL
I ANTHEM BLUE CROSS & BLUE
Patient: LAXMA GUDOOR TQZ070A22752
11852 BOOTHBAY LANE Insurance
FISHERS, IN 46037- 2
Patient No: 201203791
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY.THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND IS
DUE AND PAYABLE NOW.THANK YOU.
Total Amount Total Paid Balance
$399.92 $399.92 $0.00
CPT
Date Description;,, Charg Credits
11/29/2012 BASIC LIFE SUPP-EMERGENCY A0429 $375.00
11/29/2012 MILEAGE A0425 $24. 92
01/17/2013 COMMERCIAL INSURANCE PAYMENT,4#,q Ca0,3yZ1'/7 $399. 92
01/22/2013 COMMERCIAL INSURANCE PAYMENT / $399. 92
01/24/2013 REFUND � lfle6llG� 6�f3jj ZG' $-399.92
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
CARMEL FIRE DEPT
PROVIDER ID NO: 000000184493 01/03/13
CHECK NUMBER: 0308335250
BLUE ACCESS -
SERVICE CONTRACTUAL PROVIDER RESP. EX PU INSURED OTHER ANSI EX PLlA NSI
SERVICE DATES) CODES POS CHARGE ALLOWED DEDUCTIBLE CO-PAY CO-INSURANCE DIFFERENCE AMOUNT CODE(S) RESPONSIBILITY CODE(S) NET PAID
AMOUNT
INSURED'S NAME: GUDOOR,LAXMA R INSURED'S ID: 070A22752 _ .PATIENT NAME: GUDOOR,LAXMA R FOR INQUIRIES CALL:
PATIENT ACCOUNT/#: 201203791 CLAIM NUMBER: 2012359OA6395 RECEIVED DATE: 12/24/2012 (866) 542-4469
SERVICE PROVIDER NAME: SERVICE PROVIDER ID: 1154325579 EXPL CD:
11/29/2012 11/29/2012 A0429 41 375.00 0
375.00 0.00 0.00 0.00 0.00 0.00 0.00 375.0
11/29/2012 11/29/2012 A0425 41 24.92 24.92 0.00 0.00 0.00 0.00 0.00 0.00 24.92
TOTAL: 399.92 399.92 0.00 0.00 0.00 0.00 0.00 0.00 399.92
INTEREST PAID 0.00
TOTAILNET_PAID _ 399.9
TOTAL APPROVED AMOUNT 399.92
TOTAL INTEREST 0.00
TOTAL NET AMOUNT DUE: BLUE ACCESS 399.92
GROSS APPROVED CLAIM AMOUNT 558.72
TOTAL INTEREST 0.00
NET AMOUNT DUE 558.72
EXPL CODES EXPLANATION
MCP THE CHARGE EXCEEDS THE MEDICARE ALLOWABLE AMOUNT FOR THIS SERVICE.
23 THE IMPACT OF PRIOR PAYER(S) ADJUDICATION INCLUDING PAYMENTS AND/OR ADJUSTMENTS.
01/05/13 03083352250 0103AI030122-015376 -�
ANTHEM INSURANCE COMPANIES, INC. 79604
DBA ANTHEM BLUE CROSS AND BLUE SHIELD
\��/� 1351 WILLIAM HOWARD TAFT ROAD
. `�'® CINCINNATI, OH 45206-1775 1 oT 3
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Blue i ross and Blue Shield Association,
rOaOlue nos,and Blue Shield Association
dC the Anthem Insurance Companies,Inc.
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CARMEL FIRE DEPT
2 CARMEL CIVIC SQ
CARMEL IN 46032 0
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RECEIVED JAN 2 2013 LN
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ANTHEM INSURANCE COMPANIES, INC. CHECK NUMBER 0308335250 DATE 01/03/13
P.O. BOX 37010 y, PROVIDER NAME CARMEL FIRE DEPT
LOUISVILLE, KY 40233-7010 ADDRESS 2 CARMEL CIVIC SO
CARMEL IN 46032
PROVIDER ID NO 000000184493 - 1154325579
888-290-9160 TAX ID NO XXXXX0972
PAYMENT SUMMARY
GROSS APPROVED CLAIM AMOUNT 558.72
r--- IRS WITHHELD 0.00 M
INTEREST PAID 0.00 I °
STATE WITHHELD 0.00 m m �q.
0
PENALTY PAID 0.00 I AMOUNT PREVIOUSLY OVERPAID 0.00
NET AMOUNT DUE 558.72 j AMOUNT DISBURSED 558.72 >
RECOUPMENT BALANCE 0.00 N LL:
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CHECK NUMBER ni
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CINCINNATI,i 081145206-1775 !,li m2
t 0103AI030122 015376 C007422 32997771'3811 III >D
PROVIDER ID NO i, �III'I"I TAX ID NO 'i DATE CHECKAMOUNT.,IIiI�III �nr
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Details on back.
11°030833S2SOo 11.06 1 1 12 713811, 329977713aI1a
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))
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
.IAN 2 890"1
OvIt
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund