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Home My WebLink AboutInv# 21061100003575 - SUNSHINE STATE HEALTH PLAN - 09/30/2021D[tn C\ MANUAL REFUND REQUEST FORM TO: FINANCE DEPARTMENT OF BROWARD SHERIFFS FIRE RESCUE BELOW REPRESENTS A REqUEST FOR YOUR ORGANIZATION TO ISSUE A REFUNO FOR THE FOLLOWING ACCOUNT. THE REFUND CHECK MUST 8E I55UED TO THE PAYOR/PATIENT SHOWN SEI.OW. PLEASE CONTACT CI.IENT RELATIONS SHOULD YOU NEED FURTHER INFORMATION. REFUND DETAITS: PATIENT ACCOUNT# REFUND PAYABLE TO: NAME: ADDRESS: CIW, STATE ZIP ADDITIONAT INFORMATION: \32* R\ 61488539 DATE OF SERVICE: 6/7r/202L PATIENT NAME STEWART SERODY REFU ND AMOUNT: 590.16 REFUND REASON: OVERPAYMENT: MEDICARE & SUPPLEMENTAL INSURANCE PAID INSURANCE CLAIM #: U200FLE 15560 SU NSH IN E STATE HEALTH PLAN ATTN: PROVIDER REFU ND PO BOX 864986 ORLANDO, FL 32886 N/A Broward Sheriffs Fire Rescue PO 8ox 865346 Orlando, FL 32886-5346 Account # 61488539 Itemized Statement Patient Serody, Steward 453,1 SW 42ND TER DANIA FL 33004 Trip Date of Service: 06-1'l-202'l lncident #:: FDN21061 100003575 Pickup: 4531 SW 42ND TER Destination: MEMORIAL REGIONAL HOSPITAL Itemized Charqes Description Unit Gost U nits Amount Base Rate oaniaALSl Emerqency 1 167.30 1 1 167.30 ALS Emergency Mileaqe Dania 21 .55 4.9 105.60 Account Detail Transaction Scan #Post Date Amount Payment to EMS - Primary lnsurance 0s14001 12 o7-15-2021 390.53 AdiustmenUAssiqnment - Primary lnsurance ps'1400112 07 -15-2021 784.73 Payment to EMS - Secondary lnsurance i1628022221300 08-04-2021 90.1 6 AdiustmenvAssiqnment - Secondary lnsurance n62ao22221300 08-04-2021 7 .48 Payment to EN,1S - Tertiary lnsurance ps'1440510 08-24-2021 97.64 AdiustmenVAssig nment - Secondary lnsurance i1628022221300 08-26-2021 -7 .48 Pavment to Ei/S - Secondary lnsurance '1407685066 08-26-2021 -90.16 Account Su mmary Total Charges $'1272.90 Total Payments $488.'17 Assign/Adjust $784.73 Balance Due $0.00 Printe.l on 08-26-2021 P.O. BOX 3411 acHANlcsBURC, pA 17055 - 13 50 COIITTY OF BROWARD OFRICE OP oRr.ANm, EL 12a86 5l{5 EIN: CIECK DATE : PRODUCTION DATE : 596000s34 7137262555 404320342 07 /16/202710053.4f o7 /14/2O2r SERV DATE POS NOS PROC "ODS BILLED AI,IO'IED DEDOCI COINS GR!/RC AI{I PROV PD taA}{E:SERODl, SIELA.RD CORAECIED: NA HICN:cLll Slalus:19 IRN: 0611 061121 0611 061121 PT RESE 97,54 a1 1 AOa27 RII41 4.9 A0rl25 Rrl SOB TMALS PREV PD O.OO IMEREST O.OO 450.78 0.00 90.16105.50 11-39 0.00 7.44 7212.90 480.1? 0.00 9?.64 i.ATE FILIIIo CIIARGE O.OO 116.52 160.626e.2L 29.9t 704.1, 190 _ 53 CLAIM INEOR!{aTION PORIARDED fO: UNITEDHEALTH CROOP AC$T: X6 !4 3 33l9A0 ICN:0921131394000 NFr 390.53 co-45 TO1ALS: I OE CIiI S BILLED Ai(! A!LO1iED AIrr1 1,272.90 188.1? DEDOCT AMI 0.00 190.53 10053 _13 co-Adju6trent, G!ou9, Reason, !DA, and ReMtk codeec;tractual obtig.lions. The p.Eient @y noE be bitled fo! ihiE arcuE 4schalge exceeds f;e Bchedul./m;xirum all;ua}le o! coorlacr.d/lesislared fee allatrge@nt. Note: rhis adjustfrenE .*"it ."-"c eqrul rhe !oEa1 6.*ice o: claim chalge arcEi; and musE tro! aluplicaEe plovidcr adjus:oent amoEts {payrerEE and c6ntracr.uar r.atucEions) Eh.r have reBulled fror prio! payells) adjudication. (UBe ody ei.h croup codes pR o! co dependinq upon liability)Pa!i.n. Responsibiliry2 Coin6ulatrce Arcun!afelE: rf you do nor agre. rirh rhaE ee approved fo! .hese Eerviceg, you @y aptrca1 ou! decision. To @ke 5ule-ttEt ,. ir. t.ii:o you, ,.-!equi!e orher iodlviduat rhaE did noi process you! initial clais to conducr lhe iPpe.I. Hor€ver, in oralr ro le .iigitr. ror an apirat, you (u6t urite !o us uithin 120 dayE of the dale you re..ived !hi6 notice, unle.s you have a 9@d leason fot b€itrg late. Alert: The claim infomti;D has also been fotualded Eo rredic.id fo! leview. Aler!: The clair inforulion is also beitrg fotualiled io the paEien!'6 Buppl4enlal insurer. serd &v questionB regarding supPlerentat ben.fit8 co Ehed Page 1 Batch: Lockbox 792 MCO 865346 < Previous Transaction Eatch Summary Transaction 18 Summary Transaction Total: 1,639.8ii USD DepositAccount: 4132991530 Next Transaction > Deposit Oate:07tfinoz1 Ch6ck 1 Check Amount: Check Account Number: Check Number: 1,639.83 USD 9 7481440 10145061 Fronl lmage ! Fon sEcuRtyt punposEs, TxE FAc€ oF rHrs oocuu€Nt coNTAtNs I A a[Ue 6ack6Roulto lNo rrlcFo,,RlNrrxc rtl IHE BoioEE t SunJhillc Strtc llcxl(h Pbn l.l.rid. ( l.ii\ {$Etrl7lrx,lit^iI lnrnrrr.l I'Al Oft Iho trot! sit lluo'l'erl fhirlt Nrftr& &)/100 Drllrrt T()THF. ( ()lr\rl ()[ rR(t\i ^Ru ori'.riitttrr "' oRDER oF [?|l?*',il1i1i.,,," tr)r-(o(oq) CJ T \.u*l 5'r.ir.r. ll({rn { 'a Cn..cr I t.n i l{n 0r,/) , ,//; /L|t- t-'ar- DO I{OI CASTi lF WTYE iM AK IS IIOTPAES€NION '''IE iEVEFISE SIOE Of THIS OOCUIENT ' HOLO AT ANANGLE IO VI€W ".o Io tr.5og IN r:or. I eo t8 ?Lr: t*a ta, ,tao',. ot 0 t{506 t Drl. O7 ntt2l Chc(k Anouot Page 62 ol 136 iI ?ar' sunshine heatth I RUN DATE: CHECK #: PAYEf, ID: tRs #: 07ntzt 0t0t4J06l Pr000m66366 596000J34 (865)7964s30 00 00 00 105.50 B .00 105.50 Remittanc€ Advice ald Exphnation ofPayrneDt Continucd froD Previous Pagc AltPdlcy,i: MEAMHY5GNTTY5 Crrri.r l\'rn.: I\,IEDICARE PART A ll, B t00 061 I t05.60 .00 4i0.7E 360.52 450.78 t60 62 .00 tn.!i.d NrEc! SERODI STEWART L [t.rb..lDr 9620911822 tufi.rtNxr.: SERODY, SIEWART L rCN:x6l48E5lpA0 ScrvlccProri&r: coUNIYOFBROWARDOICSHERM'{PI: 1417262565 chllnlo: U200FLE|5560 Pturid.r ID: P10000065366 Group: FL M!'I,,/CW R.EG I0 Dryt Ct/Qtl il.d Prld ------_-fi- 'tPP u200 lt .00 .00 .00 .00 .00 Ir.!ndlt.!.:SERODY,STEWARTI. il.nb.rlD:962(BtlE22 Prd..(N.n.r SERODY,SIEWARTL ?CN! X614t853940S.ni..P idc.. COUNTYOFBROWARDOFCSHERIFNPI: 143?262565 Cl.i. Nor U200FLEl5550 Proridr ID: P 10000066166cdp: FL MM.AJCW REO l0 Cop4, Dr'3 lPfm.drr D.yr CUQty vodrnil AARP SU!?I,EI{EIIrAT- HEAI-TH ?I.ANS FRO}I UNITEDI{EALTIICARE ATLANTA, 6A tolTa 0819 cosTo!,tER sEtvrcE COIATY OF BROIIAID OFAICE OE THE SIIEE PO BOX 355346oR!Ar{@, FL ]2336 s 146 EIN: c]llEcr Mllt: CHECK OATE: PRODOCTION DATE: 59600053{ t4)7252555 11913 5172 3oe/17/2021, 3 012 .50 oa/t7/2027 pos os lRoc MoDs BTLLED AIIOWED DEDUCT COINS NAME: SERODY, STEWART L CORRECTED: NA HICN:cLx starur:2 xRN: 0511 0611210611 06112r pT RES! O.O0 RH SUB TOTALS 1157.30 450.70 0.00 0.00105.60 37.19 0.00 0.00 t272.9a 488.1? 0.00 o.0o LATS FILING CHARGE O. OO ACNI : X6143331940 rcN | 119343440311 tLla,26 NET 97.6 4 1 1272.94 4 34. 17 DEDUCT AJTIT 7t75.26 I012 .60 ^djusrnent, Group, Rea6on, iloA, add ReErk cod.soth.r adjustEnEB 23The inpacr of prior paye!(s) adjudicarion including pay@dr. and/oi.djustmencs. (Use only riih GlouP co.ie oA) Page 1