HomeMy WebLinkAboutInv# 20121900006979 - Cigna - 06/14/2021MANUAL REFUND REQUEST FORM
TO: FINANCE DEPARTMENT OF BROWARD SHERIFFS FIRE RESCUE
BETOW REPRESENTS A REQUEST FOR YOUR ORGANIZATION TO ISSUE A REFUND FOR THE
FOILOWING ACCOUNT. THE REFUND CHECK MUST BE ISSUED TO THE PAYOR/PATIENT SHOWN
BELOW. PLEASE CONTACT CLIENT RELATIONS SHOULD YOU NEED FURTHER INFORMATION.
REFUND DETAILS:
PATIENT ACCOUNT#:59ss0523
DATE OF SERVICE L2/1.9/2O2O
DINA MERCADO
REFU N D AMOUNT: 5619.43
REFU N D REASON REFUND REQUESTED BY PAYER/ PAID ON INCORRECT PATIENT
INSURANCE CLAIM #: 8222100491910
REFUND PAYABTE TO:
NAME:CIGNA
ACCT # 13 0758 2379403
ADDRESS:
CITY, STATE ZIP:
ADDITIONAL INFORMATION:
PO BOX 952366
sT. LOUtS, MO 63195
Dar'L
PATIENT NAME:
Broward Sheriffs Fire Rescue
PO Box 865346
Orlando, FL 32886-5346
Itemized Statement
Account #
59550523
Patient
Mercado, Dina
4161 Sw22ndAve#2
FORT LAUDERDALE FL 33312
Date of Service
lncident #:
Pickup
Destination
Trip
12-19-2020
FBC2012.1900006979,I096 SW 41ST CT
MEMORIAL REGIONAL HOSPITAL
Itemized Charqes
Description Unit Cost Units Amount
ALSl Emerqency Base Rate Dania 1 167.30 1 1 167.30
ALS Emerqencv l\4ileaqe Dania 21 .55 5 107.75
Account Detail
Transaction Scan #Post Date Amount
Payment to EMS - Primary lnsurance ps1 1 71839 01-13-2021 619.43
Payment to EIVlS - Primary Insurance 1377886358 05-07 -2021 -619.43
Account Summary
Total Payments
$0.00
Assign/Adjust
$0.00
Balance Due
$1275.05
Total Charges
$1275.0s
Printed on 05-21-2021
Batch: 992
Lockbox: l\4CO 865346
Transaction 11 Summary
Transaction Total: $0.00
Deposit Account: 4132991530
Deposit Date: 0212412021
Item 1
Front lmage
Dept 19425
PO Box 1259
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Febtuary 17,?a21
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Ei*
BROWARD SHERIFFS FIRE RE
PO BOX 865346
oRLANDO FL 32886-53€
Shr.,/ M,xuo4a
;\ti:cigno" Ohms
Coresponderce Address:
9140we.st Dodge Road
PO Box 542007
omaha, NE 68154-8007
Phone: 888-633-5516
Nebraska: 402-344-51 oo
TTY Phone:711
ACCOUNT NUMBER:13 0753 2379403
Re: Request ror rerund or overpayment. Oin*: 596000534)
HMS has been enlisted by CIGNA HEALTHCARE PROCLAIM ro recover the amollnt indicaled betow_
We rospsctrully rcquest you. remitlance in lull, payable ro eilherHMS orlo the above menlioned cllonl. Ploass send lhe refund
or contact our otiice within 30 days or lhe dale of thas letter.
For questions aboul this request contacl our omce direcily or submit your lnqulry in w ing to the cofiespondence address
SHERRYJOHNSON
HMS
1-88453+5516 exl. 8700335
Business Houls - cSTi
Monday -ThuMay 7100 a.m. io 5:00 p.m
FridayT:00€.m. to 3:45 p.m.
The ove.payment ideniified is tor ihe beiot! custome. and conelalesto lhe
See Reverce for Calculations and Additional lnformation
NlRPoRno*w]TItP^YM[."T
Account Number 13 0758 2379403
Please do nol use slaples on yourremittance.
BROWARD SHERIFFS FIRE REPO BOX 805346
ORLANDO FL 32886-53,1€
HMS
PO Box 952369
St. Louis, MO63195.23S
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0r, 00000130?s8el?trl0t E 000!!!61tr{3 1:?Lll,a;Lla5Et t
$519.43paid on incorrcct patie.Uirsurcd
ANA MERCADO
12t19D420
51,275.05
6619.43
ANA MERCADO
x5955052340
TfiAfiA
Page 26 of 51
Amount Enclosed $_
Batch: 992
Lockbox: MCO 865346
tiansact on i T Coft hued
Transaction Total; $0.00
Deposit Account: 41 32991 530
Deposit Date: 0212412021
Back lmage
42221444"
11,275.05 $0.c0 50.00 5619.d3
12142424
la '12 19 2020
$0 00
Ac..unl N!hb.r:13 0753 2379103
ln sccodancev th requiremenis for rcquesls for ref!rd oroverpaymenls or claims eslablished under Florida aw, a prov der
shallbe notified inw.ilinq oI any monies ihe providermay owe, forany reason, and the prcvider shallhave (i) lorty (40) days
from receipl ofsuch noliflcationlo rcfund overpayments of claims;or (iD lhidy five(3s) days ircm €caipt ofsuch nolificalion
to conlest or deny the requesl. The pmvideis oonteslation or denial of overpaymenl ol clalms owed musl be in wriling and
must slale lhe speoifio reason for coniesting ordenying.
Item 2
Page 27 of 51
$r 275.0s
I
$o.oo 134 3441r3 ol-r 1-2021
82221004 | a955a52lA to.oo
|
5o.oo 33r38aaos
I
o1-r r-2021
oRLANDO, i'L 32€36 5:146
E IN:
CRP/RC AiIT PROV PD
GRP/POL NUIj:31367?2 t279 12tr2n2A 1167.30 ?19_34 0.00 143.9?54.45 0.00 10.39
1215 .45 174.29
rcN:322210Cl 914
Adjustment, Group, Reason, I"roa, and Remark ..descontracaual obligations. The patient may not be bil1ed for this amount
45charge exceeds fee schedDte/maximum allcHab1e or cotrtra.ted/leqislated fee arrangement. Note: This rdjustmenl
equal the total service or claim charqe amount; and mxst not dupli.ate provider adjustment amcunts
lpayments and .ontractual reductions) that ha,e resulted from prior payer(s) adiudication. (use only uith Group
Codes PR .r Co depending upoD 1iab1lity)Patient Responsibility2 Coinsurance Amount
Page 1