HomeMy WebLinkAboutInv# 21052400003154 - SUNSHINE STATE HEALTH PLAN - 09/30/2021MANUAL REFUND REQUEST FORM
ro: FINANCE DEPARTMENT oF BROWARD SHERIFFS FIRE RESCUE
BETOW REPRES€NTs A REQUEST FOR YOUR ORGANIZATION TO I55UE A REFUND FOR THE
FOLI.OWING ACCOUNT, THE REFUND CHECK MUST BE ISSUED TO THE PAYOR/PATIENT SHOWN
BELOW, PLEASE CONTACT CLIENT RETATIONS SI]OUI.D YOU NEED FURTHER INFORMATION'
REFUND DETAItS:
PATIENT ACCOUNT#:
REFUND PAYABTE TO:
NAME:
6t290867
DATE OF SERVICE: 5/24/202L
PATIENT NAME TRICIA SMITH
REFUND AMOUNT: S94.19
REFU N D REASON COB: MEDICARE lS PRIMARY
INSURANCE CLAIM f: U 183F1E41643
tzs37 p\
ATTN:PROVIDER REFUND
ADDRESS
CITY, STATE ZIP:ORLANDO, FL 32885
ADDITIONAL INFORMATION:
Don'o'-
SU NSHINE STATE HEALTH PLAN
PO BOX 864985
Account #
61290867
Itemized Statement
Patient
Smith, Tricia
30 SE sTH ST
DANIA FL 33004
Trip
Date of Service: 05-24-2021
lncident #:: FDN21 0524000031 54
Pickup: 30 SE 5TH ST
Oestination: MEMORIAL REGIONAt HOSPITAL
Itemized G es
Descripti on Unit Cost Units Amount
ALSl Emergency Base Rate Dania 1 '167.30 1 1 167.30
ALS Emerqency l\4ileage Dania 21.55 79.74
unt I
Transaction Scan #Post Date Amou nt
Pavment to E[,lS - Primary lnsurance ps1385409 07-02-2021 383.20
AdiustmenVAssiqnment - Primary lnsurance ps1385409 07 -02-2021 768.03
Payment to EMS - Secondary lnsurance i'1626280302936 07-15-2021 190.00
Payment to EMS - Secondary lnsurance 1405303409 08-17 -2021 -94. '19
Account Summary
Total Charges
$1247.04
Total Payments
$479.01
Assign/Adj ust
$768.03
Balance Due
$0.00
Printed on 0&17-2021
Broward Sheriffs Fire Rescue
PO Box 865346
Orlando, FL 32886-5346
I,IEDICARE PART BP.O, BOX 3411
I,IEC'iANICSBURG, PA I7055 1O 5O
COUNTY OF BROT'AR! OFFICE OF
PO BOX A6 5346
oRLANm, FL 323a6-51a6
EIN:
CIGCK DATE :
CHECK A, T:
PRODUCTION DATE :
1411262565
a1/a5/2O2r
o7 /0\/2027
SERV DATE POS NOS PROC XODS BILLED ANLOWED DEDUCT COINS GRP/RC AMT PROV ?D
NAIIE:S|ITH, TRICIA
CORRECTED. taA HICN:
cLl{ srarus:1 xxN:aa24 05242t
MBR.aI87VY5CU52 ACm:X6t29Oa67A0
ar I A0a27 RH 116?.30REll: N7a2a1 3.7 A0425 RI{ 79.74
REll: N7A2
SUB TOTALS L211.O1
PRIV PD 0.00 rmERlsT o.o0
450.78 0-00 90.16
28-21 0.00 5.55
,I?9.01 0.00 95.41
I,ATE PILIIIG CIIARGE O.OO
716.52 360.62
51.51 22.54
76A.03 361.20
NEr 343.20
ICN | 1A21r?2634?30
oa24 0a2421
El RESP 95.41
TmA!S: S OP CLAIMS 95_81SILLED Ar'fr CHECK AIIT
AdjEtneD!, Group, Reasotr, rroA, and Re@!k cod.s
conlrac.ual obligarions. The paiienE @y noE be bilred foi thi6 arcudt{sc;rse ercee.L. f;. schedure/m;inur alr;ra!1e or cooE:acred/r.cqislaEed ree atanseenE. Note: rhis adjuatmenl
.*""t..*"t.qual rhe toral selvice o! clair.halge amount, and musi trot dlplicaEe plovid.r adjuBhent arcunts
(pay@nrs an.t coantract""r ieducrioE) trEt have resul!.d from prior Pay.r(s) adjudicatlon. (use only vith cloup
Codes PR o! cO depending upon liability)PaEietri Relrbnsibili!y
2 CoiEurance Arcun!rr.'t.Itvo"donotagreelithrhAt,eapprovedfo'tbeseseryiceE,youMyapp.alou!decision.To@keBur.-th.tre are fai; ro you, ,. lequire anorhe! i;ividual lhar did not procear you! initial craim to couduct the appea!.
Horeve!, in oider !o be eiiqrtre tor an app€al, you rust ,!ite Eo u5 rithin 120 day6 of Ehe date you received this
nolice, unlesB you have a g@d leaEon fo! b€ing laEe.
Aler!, No coinsir.nce @y;e co11e.red as peEi;nr i6 a Medlcaid/Qualified xedicale sen.ficialy. Revie* vou! tecolds
for any ,lonqfully colrected .oinaulanc..
Page 1
Batch:
Lockbox
766
MCO 865346
< Previous Transaction Next Transaction >
Deposit Date:07t12t2021
Ch6ck 1 Check Amount:
Check Account Number
Check Number:
760.00 usD
96/.7481440
'1014011,|
Front lmage
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Check Amount
Page 96 of 166
Batch Summary
Transadion 37 Summary
Transaction Total: 760.00 USO
OepositAccount: 41329S1530
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