HomeMy WebLinkAboutInv# 21030300001319 - BLUE CROSS AND BLUE SHIELD OF FLORIDA - 09/30/2021hn'u
MANUAL REFUND REQUEST FORM
TO: FINANCE DEPARTMENT OF BROWARD SHERIFFS FIRE RESCUE
BELOW REPRESENTS A REOUEST FOR YOUR ORGANIZATION TO ISSUE A REFUND FOR THE
FOLLOWING ACCOUNI. THE REFUND CHECK MUST BE ISSUED TO THE PAYOR/PATIENT SHOWN
BEI.OW. PTEASE CONTACT CLIENT RELATIONS SHOULD YOU NEED FURTHER INFORMATION.
REFUND DETAITS:
PATIENT ACCOUNTS
REFUND PAYABTE TO:
NAME:gzkv rIBLUE CROSS AND BLUE SHIELD OF FLORIDA
DEPT. 1213
PO BOX 121213
60357750
DATE OF SERVICE: 313/2027
PATIENT NAME:BEATRIZ ETENA GATVEZ
REFUND AMOUNT: 5429.05
REFU N D REASON OVERPAYMENT: OTHER INSURANCE PAID
ADDRESS
CITY, STATE ZIP:DALLAS, TX 75312
ADDITIONAT INFORMATION:
INSURANCE CLAIM B: H 100000876721243
Broward Sheriffs Fire Rescue
PO Box 865346
Orlando, FL 32886-5346
Account #
60357750
Itemized Statement
Patient
Galvez, Beatriz
730 N TOTH TER
HOLLYWOOD FL 33024
Trip
Date of Service: 03-03-2021
lncident #:: FDN21 030300001 319
Pickup: 2 DIXIE HWY
Destination: MEMORIAL REGIONAL HOSPITAL
ized ha
Descri ton Unit Cost Units Amount
ALSl Emergency Base Rate Dania 1 167.30 1 1 167.30
ALS Eme n Milea Dania 21 .55 3.4
nt Detail
Transaction Scan #Post Date Amount
Payment to E[/S - Primary lnsurance ps'1266542 04-01-2021 429.O5
Payment to EMS - Prima lnsurance o410022766478 05-03-2021 'l 1'16.51
Pa ment to EM Prima lnsurance 1407698528 08-26-2021 429.05
Account umma
Total Charges Total Payments Assi n/Adjust Balance Due
't240.57 1116.51 0.00 124.06
Printed on 08-26-2021
Flordc" alue @@
An lndependent Licensee of the
Blue Cross and Blue 5hield Association
For forms with attached checks, please mail to:
Blue Cross and Blue Shield of Florida
Dept. l2l3
PO Box 121213
Dallas, TX 75312-1213
OR Express Courier Service (e.g., DHLo, FedEx@):
Blue Cross Blue Shield of Florida
l,ock Box E91213
1501 North Plano Rd
Richardson, TX 75081
For forms without checks,
please mail to:
Florida Blue
P.O. Box 1798
Jacksonville, FL 32231
Claim Overpayment Refund Form
Overpayment refunds will go directly to a secured bank lock box to maintain the accuracy and timeliness
of applying refund checks.
1. Provider Name County of Broward Ofliff BCBSF lnvoice Number
BCBSF Provider Number A0692 Refund Oate 0812912021
National Provider ldentifier (NPl) 19;372621 Claim Number H100000876721243
Patient Name BEATRTZ GALVEZ Date(s) of Service 0310312021
Patient contract Number LAM839002040 claim Paid Dale 041o112021
2. Reason for Refund (Explain the reason the money is beingreturned.)
IAnother carrier also made payment. Attach other carrier EOB.
lncorrect contract number. Incorrect patient contract number
Conect Patient contract number
Can't identify patient. Paid wrong provider.
Procedure or diagnosis code enor. Attach corrected claim.
Returning duplicate BCBSF payment. Duplicate of claim number
Services billed in error. Attach corrected claim.
Other BcBSF payment error. (Be specific)
3. Refund Check Attached Amount of refund M29.05
900-0954-1 1 17
Yes
November 2017
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1
43OO DEERTIOOD CAr,iPUS PA.ruOIAY
JACKSONVILIE. EL ]2246
COUNTY OF BROTIARD OFFICE OF THE S
PO BOX 919068
oRLAIDO, PL 32 3 91- 9054
EIN:
CHEC( DATE :
PRODUCIION DATE:
596000534
L26A6
141126256s
2oaa00a19
01/o\/2021
9410.91
SERV DA1E POS NOS PROC MODS BILIED AILOI{ED DEDUCT COIIIS GRP/RC AIilI PROV PD
NAI',E:GALVEZ, BEATRIZ
CORRECTED: NA HICN:
cl,l'{ sratu.:1 !.lRN:t411262555 o3ol 030 321
MBR:I,A s1900204 0 ACNT : X50 35775040
RH 1167.10
N130 N331PJt 73.21
N130 N3a1
su8 ltnA's 1210.57
IMEREST O. OO
1167.!O 0.00 i15.06 PR-95
1r.27 0.00 2-59 PR-95
12{0.57 0.00 47.57
IATE IILIIIG CHARGE O. OO
776.52 405.70
47.33 23.15
753.a5 429.05
NF! 429. 0 5
ICN:Hr00000376721241
7471262565 o l0l 0l0121
?T RESP 81r.52
ToTAl,S: I or CLAIMS BILLED A]t{?
1240.47 429.0s
CI{ECK AITI
9410-91DEDUCI A-llfT
Ntal
Adju6lment, Gloup, eeason, rcA, and Re@!k codes
PaEien! ResPodsibilitYg5Non,cover.at_ cbarge (B) - A! reas! on. ReGlk cotle tusE be plovided (@y b€ coirPrised of .ithe! lhe NCIDP Rejec!
Reason Code. o! iemlrEaoce Mvic. ReBlk coale Ehar i. nor .n ArrEst. ) Note: Refe! to Ehe 635 H.althcale Policv
rd.ntificatlon segretri (1oop 2l1o Seryic. Pa,@n! Infotution REF), if present'
2 Coin6uradce Nrcunti""."rt pr." bencfit do@@nts/euidelines fo! infolMtion abot lestricliotr' foi lttis seryice'
At.rr: c;@utr our conllacrul agleercnr aor ledElicrions/bi11in9/payme!! inIoffiEion relaE€d !o lheBe chalgeB.
Page 1
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410022766/,78
2021-05-03 11:17:27 8410Q227 6647 8
Batch: 688
Lockbox: MCO 865346
< Previous TEnsaction Next TIansaclion >
Deposit Date: 04 |0/2021
Check 1
Front lma96
Item'l
Front lmago
CheckAmount $1,115.51
Check Number: 7176212
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Page 16 of 5S
Batch Summa.y
Transadion 9 Summary
Transaction Totalt $1,1 16.51
Deposil Account: 4132991530
Check Accounl Number: 4125316976
COt llTY oF BRO'/gaRD OFEICE OP TH
PO BOX e 553{5
ORI,ANDO FL 32 86E
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410022766/,78
2021 -05-03 1'l :17 :27 8410022766478
Batch: 6E6
Lockbox: MCO 865345
< Previous Transaclion Batch Summary
Transaction 9 Continued
Transaction Total: tl.1 16.51
OepositAccount:,t132991530
Next Transaction >
Deposit Date: 0.1/3012021
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