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HomeMy WebLinkAboutInv# 21011900000369 - HUMANA HEALTH CARE PLANS - 09/30/2021( n\ MANUAL REFUND REQUEST FORM ro: FINANcE DEPARTMENT oF BROWARD SHERIFFS FIRE RESCUE BELOW REPRESENTS A REQUEST FOR YOUR ORGANIZATION TO ISSUE A REFUND FOR THE FOLLOWING ACCOUNT. THE REFUND CHECK MUST BE ISSUED TO THE PAYOR/PATIENT SHOWN BEtOW. PLEASE CONTACT CLIENT RETATIONS SHOULD YOU NEED FURTHER INFORMATION, REFUNO DETAILS: PATIENT ACCOUNTfl: REFUND PAYABLE TO: NAME:HUMANA HEALTH CARE PLANS ATTN: REFU ND AD D RESS:PO BOX 931555 CITY, STATE ZIP:ATLANTA, GA 31193 AODITIONAT INFORMATION: 59883069 DATE OF SERVICE:t/ 19 /2o27 PATIENT NAME:ANTHONY FEOLA REFUND AMOUNT 543.49 REFUND REASON OVERPAYMENT: AUTO INSURANCE PAID INSURANCECLAIMf: 820210530137882 r+t?+ ?\ G Broward Sheriffs Fire Rescue PO Box 865346 Orlando, FL 32886-5346 Account # 59883069 Itemized Statement Patient Feola, Anthony 267 Sw l2th St DANIA FL 33004 Trip Date of Service: 01-19-2021 lncident #:: FDN21 01 1 900000369 Pickup: 1440 OIXIE HWY Destination: MEMORIAL REGIONAL HOSPITAL Itemized Charqes Description Unit Cost Units Amount Dan iaALSI Emergency Base Rate '1 167.30 1 1 167.30 ALS Emergency Mileaqe Dania 21 .55 2.9 62.50 Accou nt Detail Transaction Scan #Post Date Amount Payment to EMS -Primary lnsurance 0s1229058 03-02-2021 232.9',| AdiustmenuAssiqnment - Primary lnsu rance ps1229058 03-02-2021 756.89 Payment to EMS - Pri mary lnsurance p4100'1 5383387 06-18-2021 76'1.46 AdiustmenuAssiqnment - Primary lnsurance ps1229058 06-23-2021 -756.89 AdiustmenUAssignment -lnterest Payment p4100'15383387 06-23-2021 3.76 AdiustmenUAssignme nt - Primary lnsurance p410015383387 06-23-2021 282.68 AdiustmenUAssiqnment - lnterest Payment 139'1401935 06-23-2021 -3.76 -AdiustmenuAssignment-Pri mary lnsurance 1405289789 08-17-2021 -282.68 AdiustmenVAss ment - Primary lnsurance 0410015383387 08-17-2021 278.92 Payment to EMS - Primary lnsurance '1405289879 08-'t7 -2021 43.49 Account Su mmary Total Charges $1229.80 Total Payments $950.88 Assign/Adj ust $278.92 Balance Due $0.00 Printed on 08-17-2021 HUI(ANA INC. LEKINGTON, KY 40512 4601 COUNIY OF BROTIARD OFC SIIERIFF ?o Box 36 5146 ORLANDO, FL 32 6A6 EIN: CHECI( NU}T : CHECK DATE: PRODUCTION DATE: 595000534 7411262365 02/2A/2a2r 69600.3302/2A/202r SERV DATE POS NOS PROC l,lODS BILLED AI,I,OI'ED DEDUCI COINS GRP/RC-A}IT PROV PD NAXE: aEOLA, ANTHOIY CORRECaED: FEOLA, AIIIXOT{Y GR?/gOL NUX:0Y065101 UBR:H45913541IiICN:H45913591 01r 9 011921 1L 2 40425 1167 .l0 52.54 1229_S0 sx SIJB TOTALS IFTEREST O.OO 22.L3 0.00 0.00 172.91 0.00 o.0o INTE FII,IIIG CIIAIGE 2L0.74 22. !3 212.91 ACIIT: XS 9ag 3 069A0 !or: I2o2105301373a2 450.73 0,00 0-00SH 0119 011921 co-45 co-45 PT RESP 24O.OO NET 2 32 .91 IOIALS: * OF Cl,AlUS DEDUCI A!17 2!2.91BILIED AIiTI t229.aAL adjusE@n!, Group, Rea6otr, r4oA, and ReBrk .odegPatien! ReePonaibility 3 co-payi.nt ArcunrConilac!@I obligations. rte Patien! @y dot be billed for this a@st rsiiiig..i;."a" r;e 6chedule/n;i@m all;rabre or comracledl1.sislated fee alraneeretrt. Nore: 'rhi6 adjustm.nt .;;r **"i equal rh€ loral s.*i.e o! cr.im chalse amou., and @sr not duplic.te ptoviale! adiusEm.nt anout5 (paymenEB aDd cdatractuar r..tucEions) chat ha€ !e6u1.ed rroo prio! Paye!{3) adiudication. (IrEe ontv riEh Glou9 codes PR o! co depen<tr nq upon tialiliLy) Page 1 illtililil!il ilil [ililll[ 410015383387 < Previous Transaction Batch Summary Transac'tion 15 Summary Transaction Tot€l: 76'1.,16 USD DepositAccount: 41329S'1530 2021 -06- 18 1 6:22:58 841 001 5383387 Next Transaction > Deposit Date:06t11t2021Batch: 733 Lockbox: MCO 865346 Ch6ck 1 Check Amount: Check Account Number: Ch6ck Numben 761./t5 USD 4239694516 203765s505 illlfllillfllliHllll 4't00153E 33E7 Front lmage !.,.1E9 PAY EAA'I.V t.**-76t.a6 t.og..r* Altr.l'l xur... Cerf.,,, ATJITSTZID 9OiATURS PROaREI'IYF @;g.-61 I&.6,:Ort 203r665505 9&AI: s€Et Hroifo strwat! rD a9laa 2AY _O 8iL'VrAriD irtnEs ait R:5(!i:rf lnDfr (JJV WMgit 2i,92S{Al? {rx? ttoLr aflIl3r,l, I.e0t?995505, r:oLllolScl5r: q e lcsqLs lsr. + ^ '47,b 2 4 Page 26 of 120 tt7 illtililil!il ilil [Iilil l[ 410015383387 < Previous Transaction Batch Summary Transaction 1 5 Contnued Transaction Total: 761.46 USD DepositAccount: 4132991530 Next Transaction > Deposit Date:06t11t2021Batch: Lockbox: 733 MCO 865348 Item 2 F ont lmag€ a, r|4$ w68h(r dl.rri. trat rlol, T'lp. R 3356 PROOREIIII/F 5104,1-t !65 I AB 0 ,t23 Clr8lol( 009 000365 EiowAnD sHEnffis Fti! SESCUE to FxEL5 onuNDo, FL '8ltcr:t{6r.,rrl,r,trrr.rnJl.rllIl,rl.[,rrrl!l,4r,lrrl.rtrlft i.l. aDuG toR PAYtr.tr T 203756s56 ?.!Err BNO{AND SIIEfrF5 ERE T5CUE FiryrErt D.L 06062021 Iotd Parnart Aio0nt !761.46 Totrl tlurh., ol lnvok .1 yd, have any que'irlr' eqa&{ d* paIne .*ise rall rE d 1€00.22-448) D.* Ir96&l ovr@r ,rtstrcrhaa(ry 1761.46 f ull o..diption of cot.ragp: PIP - Pclonal lnhry holtoion Nldle .Pf{6 to Ndned lnsud alld SPdEr Page2g oI 120 2021 -06-1 I 1 6:22:58 84'l 001 5383387 Tolal tayme Arnoutt : I I i I ks^lxrdYr lr/rgm2i.ll"''52trao' illtIfiililtItil I]uil t[ 410015383387 < Previous Transaction 2021 -06-18 1 6:22:58 841 001 5383387 Next Transaction > ItBm 3 Front lmag€ ao ibnlr Hlct lodd{,{ 5'l&br0 L!lP., F. !:l6ct MD$IABD }IERFs FR€ RESO'€ P0 80x 85!346 08u tDo, FL n$&53{5 lf, t{r trlln Explanation of Benelits This is not a bill PROORET'IYI' Uid.rrftrr ly: tlgr.rtlct At!.dr.n hturan.. Corp.ry oonnl D*r rJE 6, 2021CU.rlrar: 11.929/02lrlt d lE lrrs,19. :021t Ict brCrtrlo, DBEA tEb rt rr.4.!..u rL C.r.r.it ttrC ?t6dC hi4 h16ht' Da. Ldt d &.1 30. x21 ail ldrb.r:6t2681F{i&lrr.k lfiDrt i,rqnt ar. btlk &ia.i: lelo43tt-b-lt r66qE tr-i..r*.rrd.'E8$'tpffi 8EEl(Ut FO U!G:I6 0{.aND0. fL luE6 l(D Di.gnodr CoAa Di{norii Poirftcr Coi @ion ox PtdA S1991XA UrBp.o'i.d iniry of dgit tioul&( ad upper dm, hidal en@{ t'B n$ Nc.d l,<o jl{loll5 supdvkion lG) Pro.edurE Co&< [o EE (o& nnsd fu $b b!. Ch r.d o.dr.dbl. Applhd R.m.ining E+li cd .31 rc< th orIE 0r/19202r ll A0427 ^! 1 t],r6130 t0.m t0.00 i902 92 l0t 4m 01/r9202r z ,o425 29 t62.50 i0.00 10.00 01119no21 I1 r999t)I i3.76 ,0.00 t0.00 t3 76 85 t!.?1156 30.m $.m !95088 lo.oo 1189.42 Tor.L 11,23356 t0.00 1761 ,46 R€veoue Code (Rev cd)i tp.d&: &ftbl(. 56ra i.gbr30-gl d t-ti. oultz@t -01n92021 h9. lolS CPI rm .t9d r.d.i d& i@!d.t r N ISFICTO l99s-mlt ll,aqr l'..dd Asn i, rn ftrB n6ad Page 31 of 120 r.t] Batch: 73l:} Lockbox: MCO 865346 Batch Summary Transacdion 15 Continu€d Transaction Total: 761.46 USO DepositAccount: 4'132991530 Deposit Date: OAI'|1DO21 m! }l I ^'8 144.20 305 400 3 l0.m