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Home My WebLink AboutInv# 20011400003000 - FIRST COAST SERVICE OPTIONS - 09/30/2021Dcrni cr,. MANUAL REFUND REQUEST FORM TO: FINANCE DEPARTMENT OF BROWARD SHERIFFS FIRE RESCUE EELOW REPRESENTS A REQUEST FOR YOUR ORGANIZATION TO ISSUE A REFUND FOR THE FOLLOWING ACCOUNT. THE REFUND CHECK MUST BE ISSUEO TO THE PAYOR/PATIENT SHOWN 8€I.OW. PLEASE CONTACT CLIENT RELATIONS SHOUtD YOU N€ED FURTHER INFORMATION, REFUND DETAIt5: PATIENT ACCOUNTfl:55694234 DATE OF SERVICE 1lL4l2020 PATIENT NAME RAYMOND O. WEST REFU N D AMOUNT: 5381.44 REFU ND REASON:OVERPAYMENT: DEPARTMENT OF VETERANS PAID INSURANCE CLAIM fi: 0920237425620 REFUND PAYABLE TO: NAME:FIRST COAST SERVICE OPTIONS CASH IE R AD DRESS PO BOX 3092 CITY, STATE ZIP:MECHANICSBURG, PA 17055 ADDITIONAL INFORMATION : Broward Sheriffs Fire Rescue PO Box 865346 Orlando, FL 32886-5346 Itemized Statement Patient West, Raymond 237 NW 8TH AV DANIA FL 33004 TriP Oate of Service: 01-14-2020 lncident #:: FDN2001 1400000300 Pickup: 237 NW 8TH AV Destination I\4EI\,4ORIAL REGIONAL HOSPITAL Item s Description Unit Cost U nits Amount ALS'1 Emerqency Base Rate Da nta 1111 .72 1 1',|11.72 ALS Emergency Mileaqe Dania 20.52 4.6 94.39 Accou nt Detail Transaction Scan #Post Date Amount Payme nt to EMS - Primary lnsurance ps1006720 08-29-2020 381 .44 AdiustmenUAssiqnment - Primary lnsurance ps'1006720 08-29-2020 727.37 Pay ment to EN4S - Primary lnsurance 9s1224611 02-26-202',|340.57 AdiustmenUAssig nment - Primary lnsurance ps1224611 02-26-2021 865.54 AdiustmenvAssiqnment - Primary ln su rance ps1006720 09-09-2021 -727 .37 Pa ent to EMS - Prima lnsurance 1410586702 09-09-2021 -381.44 Account u Total Charges Total Payments Assign/Adjust Balance Due 1206.11 340.57 s.54 0.00 Printed on 09'09-2021 Account # 55694234 FIRST COAST SERVICE OPTIONS. INC, WHEN EXPTRIEIKE COlNTs A OTTruTY MATERS RETURN OF MONIES VOLUNTARY REFUND FORM This form should be compl€t€d tully and accompany each unsolicited/voluniary retund check so that your refund can be properly recorded and applied. Provider or Other Entity Name COUNry OF BROWARD OFFICE OF SHERIFF nddress PO BOX 865346 ORLANDO, FL 32886 state: FL Provider Number A0692 NPI # 't 437262565 contact Person Credit Balance Department rax lD # 596000534 contact Pe6on Phone # (305) 945-2280 Amount Retum€d check # Rgquirod lnformation lf Multiple Claims indicate "YES" and include listng .patient Name RAYMOND WEST 'Medicare lD # 6PW0WH8JP17 .Claim Number 0920231425620 Claim Amount Retunded $ 381.44 Dare of Seruice From O1l14l2O2O Date of Service To O1l14l2O2O Reason Code for Claim Adjustrnent 1 1- Veterans Administration claim Billed Amount $ 1 ,206 1 1 Additional lnfo. field OIG Reporting Requlrementt Do you have a corporate integrity agreement with OIG? Are you a participant in the OIG selfdisclosure protocol? Notg: providers and other entities who are submitting a retund under the OlG s Self-Disclosuro Prctocol are not afiorded appeal rights as stated in the signed agreement pres€nted by the olc. SP lnfoifiatlon Olhor lnsurer lnformation Employe. lnfoimation lnsurance co. Name Department of Veterans Employsr Name Subscrib€r Name RAYMOND WEST EmploverAddress Line 1 lnsu.erAddress Line 1 EmployerAddress Line 2 InsurerAddress Line 2 City State Zip City State ZiP Policy # Telephone Number Telephone Number 55201FC FIRST COAST SERVICE OPTIONS. INC. WHEN EXPTRI'NCE COIJNIS4 OIJAfi/ MAIIERS For each daim the required felds to be completed on the form are noted with '. lf the requrred felds fo. specifc PatienuMBl & Claim NumbeE are nol completed, NO appeal rights can be provided for this voluntary retund. l{ultiple Claims b€ing rofunded: lf refunding multiple claims, list all claim numbers and the required data on separate forms if necessary. lredicare Secondary Payment (MSP) Retunds: lnclude a copy ofthe primary insurer's explanation of benelil (EOB) & indicate the MSP reason (see Reason Code List Below) Stati6tical Sampling: lf specifc Benef ciary/i,,lBl/Claims data ,s not available, indicate lhe methodology and formula used to delermine the refund amount and explain lhe reason for the relund Mail To Fir3t Coast Sorvice Options CASHIER at Address lisled below according to state services rendered: State ' LOB PO Box City Slate ztP lnstructions FCSO.A FCSO - B (FL) FCSO-BM&PR) [4echanicsburg, Mechanicsburg, Mechanicsburg, PO Box 3162 PO Box 3092 PO Box 3121 17055-1837 17055-1810 17055-1831 Billind/ClerlcaUNon-ilSP 0'l - Conected Oate of Servic€ Date Required 02 - Duplicate 03 - Conected CPT Code Cor.ect CPT Code Required 04 - Not Our Patient 05- Mod. Add/Remove 06- Billed in Enor ilsP/Olher Paver lnvolvemenl 07- MSP Group Health Plan lnsurance 08- MSP No Fault lnsurance Date of lncident Required OS MSP Liability lnsurance Date of lncident Required 1G MSe Wo*ers Comp (induding Black Lung) Date of lncident Required UilcaIeDs9llr 'l'l - Veterans Administration '12- lnsufficient Data 13- Pataent Enroll HMO 14- Svcs Not Rendeted 15- Medical Necessity 16- Hospice 17-other-Please Specify, Description Required 55201FC R€ason Codes for each Claim lncorrect Payment (Required to Select One Raason code per refunded claim on Foaml 532 RIVERSIDE AVE. JACKSONVILLE, F! 3 2211 COI]NTY 08 BROI'ARD OFPICE OE oRLANDO, FL tt2886-t345 BILLED A![,OXAD DEDUCT COINS EIN: EF!: CHECI( DAae. CHECI( AllT : PRODUCTION DATE 596000534 !437262565 09/or/2o2o 52 oO. l0 0a/2e/202a t 066 ) 454-900? GRP/RC-ATd PROV POSERV DAIE ?OS NOS ?ROC I{ODS NAxE:flrSI, RAIMOND CORRECTED: NA HICN: CLx Status:1 RN:01I4 011420 ACNT: X5569a23442 RH 1111.72 RH 9a,39 stB ToTA!S 1206,11 IFTEREST O.OO 45t.47 0.00 90.29 35. 05 0.00 .7. 01 436.52 0.00 97.30 I,ATE FILITIG CIiARGE O.OO 1 .22 a 5:l .96 27.49 381.4. ICN:09202 31125520 41 co 251 co 253 0t1t 0r1420 TOTALS: * OF CLAI}IS BI'LED AIiT Nm 131.44 L r20 COINS A}tT CHECX Ar'!T co- Adjusement, cloup, Rea6on, rcA, and R€Erk codes Conlracrual ob1igatj,ons. The paEien! may dot b. billed fot lhis arcutrE{5 Crulg. €xceeds lee 6chedul./@xitufr atlorabl€ or conilacred/Legi3r.E.d fee afange@nt. Noie: This .djustnenr arcunE cauo! equ.l rhe ror.l seflice o! clais chalg€ anount, and mua! not duplicare Plovidet adiustmen! arcuE8(payoeniB.nat conlracrual !€ducEions) lhat have r.Eulted from prior gayer(E) adludication. (UEe onty,ilh Group cod.s PR or co depedaling upon liabiliEy)2s3sequesrlario! - reduction in federat 8p€trdidg- PaEient Re.por.ibili.y, Coinaurance A.rcuntAt€rt: If you do not agre. sith,hat te approved fo! the6. €etuices, you nay appeal ou! dccision. 'Io Mke 6ureltEi ye ale fair Eo ,ou, ee lequire another individul iha! did @t grocess you! inj,Eial claim lo conduct th. appeal. Houe€r, in orde! !o be eliqibte aor an appeal, you tusE vliee to u3 rilhin r20 davs of th. date vou:eceived lhis DoEic., u1.ss you have a good !.ason for b.ing la!e. Page 1 BRUCE T. CI,RIE& DEPATI''IETI OF VETERANS AIFAIRS I'EDICAI, CENTE 1201 N.L. 15TIt STREgtMlAl,lI, FL 3312 5 E!.IAIL:VHAI ODCONiMUNlTI?ROV I DERCOI'XUN I CATIONS{'VA . GOV ( a?7 t 341-7513 oCC COXXUNITY ?ROVIDER COI{,IUN ! CATI ONS COUNTY OP BROTAND OFFICE OF THE SAERIEE ORI,ANM. EL 32566 EIN: NPI: CHECK DATE: 1431262565 2969422 02/t9/2a2r 3154.11 SERV DAIE POS NOS PROC XODS BILI,ED AILOI{ED DEDUCT COINS NAIE:,EST, RAYXOND CORRECTED: NA EICN:cl,l s!.tus:1 tlRN: 0114 011a20 PT RESP O.OO RH SUB T TAI,S INTEREST O.OO 1111.?2 315.03 0.00 0.00 co,1594.39 24.54 0.00 0.00 CO-45 1206.11 3,I0.57 0.00 O.0O LA1E FILII'G CIIARGE O.OO 79s.69 316 .0!59.45 24.54 365.54 340.5? ACNT:x5559421,1A0 !C :302005500013r70000 1 TOTALS: * OP CLAIT4S BIILED AIfl 1206.11 t,(0.5? DEDOCT A! 0.00 CIIECK A'.?T ,164.11 adjustmenE, Group, &e.6or, MOA, and R.Gtk code8 conElactual, obtigations. Th. patient @y no! t€ bi11ed for trri€ arcunt 4schalge exce.d! fee schedule/Mi@r allovaue o! conrracred/tegislated lee allang.rent - NoEe: This adjusEhe!! equat Ehe loial leric. or claifr charge arc6!; and mst nor dupticate plovide! adju.tEeni.@ur.(paFenrs add contr.crual reducEiood) cha! have !esu1r.d Irom p!io! paye!(s) adjudication. (use only uiEh 6roup Cod.3 PR or co dependitrg upo! liability) Page 1