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HomeMy WebLinkAboutInv# 20123100007265 - Humana Health Care Plans - 06/14/2021D&*LrP TO: FINANCE DEPARTMENTOF BROWARD SHERIFFS FIRE RESCUE SETOW 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 SELOW. PLEASE CONTACT CTIENT RELATIONS SHOULD YOU NEED FURTHER INFORMATION, 59661588 DATE OF SERVICE t2/3L/?02O PATIENT NAM E ROSE MARTEL REFU N D AMOUNT: S1,218.s9 REFU N D REASON:OVERPAYMENT: AUTO INSURANCE PAID INSURANCECLAIM#: 2O21O3tL65l78Og REFUND PAYABLE TO: NAME:HUMANA HEALTH CARE PLANS ATTN: REFU N D ADDRESS PO BOX 931655 CITY, STATE ZIP:ATLANTA, GA 311-93 ADDITIONAL INFORMATION: N/A MANUAL REFUND REQUEST FORM REFUND DETAILS: PATIENT ACCOUNT#: Broward Sheriffs Fire Rescue PO Box 865346 Orlando, FL 32886-5346 Itemized Statement Account # 59661s88 Patient Martel, Rose 6093 NW 45TH AVE COCONUT CREEK FL 33073 TriP Date of Service: 12-31-2020 lncident #:: FDN201231 00007265 Pickup: 4331 RAVENSWOOD RD Destination: BROWARD HEALTH MEDICAL CENTER Itemized Charges Description Unit Cost Units Amount ALSl Emerqency Base Rate Dania 1 '167.30 1 1167 .30 ALS Emeroency l\,4ileaqe Dania 21 .55 4.7 101.29 Account Detail Transaction Scan #Post Date Amount Payment to EMS - Secondary lnsurance p710022071636 03-31-2021 121 8.59 Pavment to El\4S - Primarv lnsurance p210022764909 04-30-2021 1268.59 Payment to EMS - Secondarv lnsurance 1382156792 05-21-2021 -1218.59 Account Summary Total Charges $1268.59 Total Payments $1268.59 Assig n/Adj ust $0.00 Balance Due $0.00 Printed on 05-2'1-2021 ffi$&v 22ti 1 Batch:658 Lockbox: MCO 865346 < Previous Transaclion Batch Summary Transaction '11 Summary Transaction Tolal: $1,218.59 Deposit Account: 4132991530 Next Transaction > Deposit Date: 03|3OAO21 Check 1 Front lmage Check Amount 91,218.59 Check Number: 1402027 133 CheckAccounlNumber:'182380186334 l\lu,l[IuL\HULl\l# : HUMANA: ,. P.O_ BOX 1460r iExltrcrou, xvlloit z-loot H0mono. oAtL otn52021 cHECKITG 1002027113 . : 7LI16! 759 - 1L PROVID(flIAXlDler.{3ERXr\n:0534.ihtdtdcDler'ottEtoimsoora}irror<r,nbcr2021O1260Ot4764.5 Z6! i I S--:1,21E59PAY IO IItEomtr oe co('JrY or BrowARo ofc !r{ n L5 a*\a!ran^u. rfl 5!t!2 PA* 0..t ')KrU5 r&, tIO r.U|8ao fl6xlto{ AtaD 59rlD0 00at tstul 8,t', -=--g?ffiiEE- rr loo eD e ? l:13'p rio?5qllgol': lBelBolEEllt rr ttem 1 Frofit lnEg€ Page 18 of 6S Batch: 658 Lockbox: MCO 865346 < Previous Transrciion Batch Summary Transaclion 11 Continued Transaction Total: $1,21 8.59 Deposit Account: 41 32991530 Next Transacllon > Deposit Date: 03/30/2021 HUMA}{ACLAIMS OfFICE P.O. BOX 1460L ,-EXTNGToN, KY 40512-4601 Humono. n4E HUI{ANA AUTOMATED REUTIANCE ADVICE Coll 1-888-357-5767 or visit HUMANA-COM E Ea H c x F,{ PCX1oAiEOR12Ircl 26202114t10@O515-MW COUNTY OT BROWARD OFC SHERIII POBOX86tr46 oRLANDO, fL 32a86-5:i46 PROVIDER ID: FEDERAL TAX ID: REMITTAiICE ID: CHECI( NUME€K BANK CODE 138889570685 )000fr0534 202703260074? 64 1002027133 1L a fit saMdrDEsrDas(EtPro !6@ THISE{OUMqC'EDSNiEAUOWABLEOIAXGE. lxstll{r acooasrD€sc mdrs4' CTIAftGE EXCEEDSFEESIfIEDUL!'MA'STUB AUOWABI€ OR CO NACIID/LEGIg4TED ,EE AiRANGEME,TI, SEtYtCECODElrItE Ir,Et{tTf'€9DE5CRrmONs 40425 tq 6ROUND MILEAGE pER STAIi fiE r,lILE AO4Z1 IR LEWL 1 EMERGENO AMEUI.ANCE TRANSPOtrr,ADVANCEO LIfE 5UPPOR' qrjt gtlc! !IF;C13ctaa c.rr6i cErq:il @rd golqt ra€rl,'EErt@ l\6IeErrlaa{o's(DAr .icis6nlE!I,N\G l.r@alalrral65 ROsE XENNETII ,28!2020 74t!207t \76130 1,16710 0.00 1,11710680/45 ll1tn070 1211712070 701,79 101.29 0.@ 0-oo 70t.29 C1AIM TOrllS u58J9 trm 50.m 0.00 0.oo 1,218.59 Esr.la llgo\sllruTY 5!-@ Tql^!"JDr..EEt'rrE! tsrut- gnltlG rryEt..q,AliY gErtlErrtheas-l.rr€&!t5*AE cfc tgras r:5&r,u5a5l o.(o to-co o00 oto q6 5r x8e le*ca.stB!-ttt 50_6 rurut tD IOdUP 'OTA5 FOE TA'ITTAIC TOIAIS 1,26859 oco1:6&59 50.!o 0.00 0,00 0.00 1:1859 EsT',IBR IIsPONsIBIUTY 5OOO israL PAID 121 Page 21 oi 69 GCHH4EGHH A0425 P,i4i EE3E PAGE 3 OF4 DAIE 03/25/2021 Back lmage Batch:687 Lockbox: MCO 865346 < Previous T.ansaction Batch Summary Transaclion 1 Summary Transaction Totat: $1,268.59 Deposit Account: 4132991 530 Nexl Transaction > Deposit Date: 04/29/2021 Check I Front lmage CheckAmount: $1,268.59 Check Number: 5386147 E xud d6te..in4r or. rbourDd r,o Hqd!.d tnd Sirry Elrht DoII.r. rn.r59/rOO a EtB ltlEtrt ,:ra rtr=t Check Account Number: 3359869800 r\ru\}truI[\U[i|l[ .:'.,::''''l; .. i: ^i- ."tn_tnblp 6rd llll&.0oo!r..:.r :x-ri st,268.59 Item I Front lmag€ . L-rt 3t-.Iit. rir. t..u,o tcx €653a6o..t..do, r! 12a36 r:/31/roro ralI/10:o EHUBB' !.oo0 5l8 s I ri ?r. ':ogttt2?88,: lts9aBq800r. Page 3 of 124 L Batch:687 Lockbox: MCO 865346 < Previcus Transaction Batch Summary Transaction 1 Continued Transaction Total: $1,268.59 Deposit Accoltnt: 4132991530 Deposit Date: 0412912021 E:H U E} EI'CHUBd GROUP OFINSURANCE COMPANIES 115ISCllrt0!,6tvay2O0 aPiarEtta, cA 30022 Page: lof lEeLiruoll- itt llart ib ' -rYJ SERV:CE ^!s O{aaclrcr ss,5cRalrJ rtl,irE PEi stti!: sE,s li.dld, Ht . tale !B@ol}a f!!!!r c@'no.J( Rs?:-tri2 Pd-dr 00& og/B,,rrrthltLrli Elc613!rr{ Pdr6nc. Eh.tofr ct*n,..{.: o.a5 oooc6,olJoa4nie mrr tl'odllrr ollac l7nr,!?iOid< t{lnlcr (e!n!rr(? Prlnl D.t u!z1l7t2t CPI anhd tr.2aaL 1 ta-IOET'rl Itlo rulll3lEd-ErQa..rnhtlb frq-6 qF6ia rx trrltrlrndrlt !t-r c.iG. t-ino.r- w7EaE,r rnE +ttrH_t aat galt$},&E itr,nt !-.arg,a5+ tcB|:rtt COEI EAETsa2lzuatt! Eqll..E!Ie-Br E.trE EA.qlr E!-@ Back Image Page 4 of 124 Next Tlansaction > I I I