221752 07/02/2013 CITY OF CARMEL, INDIANA VENDOR: T0002825 Page 1 of 1
ONE CIVIC SQUARE UNITED HEALTHCARE MEDICARE SOLS2CK AMOUNT: $180.36
CARMEL, INDIANA 46032 ATTN RECOVERY SVCS
PO BOX 740804 CHECK NUMBER: 221752
ATLANTA GA 30374-0804
CHECK DATE: 7/2/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 180 . 36 OTHER EXPENSES
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JA!,1ES BRANARD, MAYOR
June 28, 2013
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UnitedHealthcare Medicare Solutions
Attn: Recovery Services
P.O. BOX 740804
Atlanta, GA 30374-0804
RE : Letter ID 2709038 Acct# 201230291 Paula Gable DOS 07/09/2012
Dear Sir/Madam:
Enclosed you will find overpayment check in the amount of$180.36.
UnitedHealthcare Medicare Solutions processed claim and paid $180.36.
Member enrolled in Medicare hospice program.
Claim correction updated and refund issued to UnitedHealthcare Medicare Solutions.
If you have any questions, please feel free to contact me at (317) 571-2604.
Sincerely,
/"(6
Michelle T. Harrington
Billing Administrator
CA KIEL FIRE DEPARTNIE-N C
STEVEN A. COUTS HEADQUARTERS
Two QVIC SQUARE, CARNIEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615
ATTN: RECOVERY SERVICES UnitedHealthcare-
PO BOX 740804 Medicare Solutions
ATLANTA, GA 30374-0804
05/14/2013
129NHOUSlAO036401
.CARMEL FIRE DEPT AMBULANCE SVC Phone: 1-800-727-6735
ATTN: BILLING/REFUNDS Ext: 77377
2 CIVIC SQ
CARMEL, IN 46032 Fax: 1-248-733-6019
Letter Reference No.: 2709038
INITIAL REQUEST-
Dear Sir or Madam:
Overpayment Notification
UnitedHealthcare Insurance Company and its affiliated companies, which operates as (or on behalf of) UnitedHealthcare
Medicare Solutions, recently performed a review of paid claims. During this review, it was determined the
UnitedHealthcare, a Medicare Advantage organization with a Medicare contract, claim(s)on the attached list was/were
paid incorrectly.
According to our records, the claim(s) referenced on the attached list have not yet been refunded to UnitedHealthcare
Medicare Solutions. Please make your refund check payable to UnitedHealthcare Medicare Solutions, and mail the
check along with a copy of this letter and attached list to Attn: Recovery Services, PO Box 740804, Atlanta, GA
30374-0804.
If you believe these findings are in error, you have the right to appeal. If you want to appeal, you must do so within 30
days of receipt of this initial request letter by submitting, in writing, the reason for your appeal, any documentation, and
supporting material to Attn: Recovery Services, PO Box 740804, Atlanta, GA 30374-0804.
If a response is not received, UnitedHealthcare Medicare Solutions may initiate repayment by offsetting future payments
by the refund amount requested. Therefore, your prompt attention to this matter is greatly appreciated.
If a refund has already been processed, please either call the number below or mail a copy of the front and back of the
canceled check or a copy of the Provider Remittance Advice (PRA) showing the offset transaction, along with a copy of
this letter and the attached list to Attn: Recovery Services, PO Box 740804, Atlanta, GA 30374-0804.
Please contact us at 1-800-727-6735 ext. 77377 if you require additional information.
The UnitedHealthcare Medicare Solutions portal address www.unitedhealthcareonline.com can be used for submitting
claims, viewing claims status, and obtaining reimbursement information, including copies of your PRA.
Sincerely,
&acme ,fie yim #7eam
Central Region Team
Attachment
Page 1 of 2
Atlanta, GA 30374-0804 `nitedHeal care
Medicare Solutions
Phone: 1-800-727-6735 Ext: 77377
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Fax: 1-248-733-6019 z
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Letter Reference No.: 2709038 05/14/2013 D
C.
Refund Request Claim Detail for TIN: 356000972 m
A
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Claim UID Patient Patient Overpaid First DOS Last DOS Date Paid Amount Payment Amount Overpymt
Name Acct# Audit# Paid Check# Overpaid Balance
34932486 GABLE,PAULA 201230291 005190917200 07/09/2012 07/09/2012 03129/2013 $180.36 0817 40931306 $180.36 $180.36
Provider Name:CARMEL FIRE DEPT AMBULANCE SVC
Amount Enclosed:
Notes for Claim UID 34932486:
Member enrolled in Medicare hospice program.Per CMS Medicare Claim Processing Manual 100-04 Ch.11 Section 30.4 traditional Medicare is responsible for all hospice and non-hospice related claims
through the end of the month in which hospice is revoked.
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Page 2 of 2
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A/R Detail
Type Transaction Adjudication Entered Amount Reference Memo Status
Date Date Date Number
Invoice 07/09/12 07/09/12 07/08/12 $427.85 Posted
Payment 04/04/13 04/04/13 04/04/13 ($180.36) CK 40931306 Posted
WriteOff 04/04/13 04/04/13 04104/13 ($47.49) CK 40931306 Posted
WriteOff 04/04/13 04/04/13 05/29/13 $47.49 CK 40931306 Posted
Credit 05/29/13 05/29/13 05/29/13 $180.36 HOSPICE PATIENT C OVERPAYMENT UHCPosted
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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-t,sa
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
JUL 7.1 2on
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund