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HomeMy WebLinkAboutInv# 20092100005426 - United Healthcare Insurance - 09/21/2021C\ MANUAL REFUND REQUEST FORM TO: FINANCE DEPARTMENT OF BROWARD SHERIFFS FIRE RESCUE BELOW REPRESENTS A REQUEST FOR YOUR ORGANIZATION TO ISSUE A REFUND FOR THE FOTLOWING ACCOUNT, THE REFUND CHEC( MUST BE ISSUED TO THE PAYOR/PATIENT SHOWN BELOW. PLEASE CONTACI CLIENT RELATIONS SHOUI.D YOU NEED FURTHER INFORMATION. 58537821 DATE OF SERVICE:9/2Ll2020 PATIENT NAME:SAMANTHA KOHLMAN REFUND AMOUNT: S1,181.90 RE FU ND REASON OVERPAYMENT: AUTO INSURANCE PAl0 INSURANCE CLAIM f: CL3 3969017003 2165705 REFUND PAYABI.E TO: NAME: ADD RESS: CITY, STATE ZIP ADDITIONAT INFORMATION: UNITED H EALTHCARE INSURANCE PO BOX 740800 ATLANTA, GA 30374 N/A (0.. REFUND DETAITS: PATIENT ACCOUNTS: Broward Sheriffs Fire Rescue PO Box 865346 Orlando, FL 32886-5346 Account # 58537821 Itemized Statement Patient Kohlman, Samantha 18385 NE 30th CT AVENTURA FL 33160 Trip Date of Service: 09-21-2020 lncident #:: F8C200921 00005426 Pickup: 195 NB 1595 ON RAMP WB Oestination: MEMORIAt REGIONAL HOSPITAL m Description Unit Cost U nits Amount ALSl Emeroencv Base Rate Dania 1111 .72 1 111't .72 ALS Emerqency Mileaqe Dania 20.52 14.3 293.44 nt Transaction Scan #Post Date Amount Pavment to EMS - Primary lnsurance p610022620569 11-13-2020 893.04 Pavment to EMS - Primarv lnsurance os1229249 03-02-202'l 1405.16 AdiustmenVAssiqnment - Primary lnsurance p610022620569 04-06-2021 288.86 Pavment to EMS - Primary lnsurance 1418488434 10-11-2021 -1181.90 Account Summary Total Charges $1405.16 Total Payments $1116.30 Assign/Adjust $288.86 Balance Due $o.oo P tinled on 1 0-12-2021 llllr ililfl tilil1il il [[ 610022620569 2020-11-13 1 1 :49:16 86'10022620569 Batch: 524 Lockbo{ MCO 865346 < Previous Transaclion Batch Summary Transaction 35 Summary Transaction Total: 9893.04 Deposit Account: 4'132991S30 Next Transaction > Deposit Dale:'l'l I 1212020 Check 'l Front lmage Item'1 Fmnt lmag6 Check Amount: $893.04 CheckNumber: 2,l9327211 Check Account Numbe. 2220079607 uu[!]!]\N [.? lc]a7al Ir. r:oI teolsJqr: ?! eoo?qEO?/F -ElcHT-tlUNDBEEftt Ery-rHREElND.o4noo.DoLlARs....-..;:.,a.;;..-.---.i,-.......-..-_..,..1.._--.;-..1 ' . ,NO. N 219327211 /4/7?. , 8"153, 112 ME BROWARD SHERIFFS FIRE RESCUE M.il to: BroYnrrl Slcir! firE Rcscuc PO Box E65346 Orl.ndo Ii 32886-lJ,t6 cerco eEnenAL |NSURAHCe CO ONEGEICO CENTER MACON, GA 31296{001 r c,.lm.nli Sa$&uhi KghtE n . lnsur.d rblrr.: S.o.r{E KoNlM' Feil@.sym6ot a tuiEunr , _A_EI!l.:.:893,04. _ Banl ot America Sorllr PonLnd, ME 04to6 ' - 1 ctaim N'um6er:loSmzrorlsood)oor' ln Pryn.'nt ot: r@njl itijury Fed& ; . ms,olaraczoogarai2o'' i . :VOID^FIER l80DAYS' .rhtet 1tp9a02o ; Amounli s*T.893.04 Page 84 of 108 lfl ililtillillil[[ 610022620569 2020-1 I -13 1 1 :49:1 6 861 0022620569 Batch: 524 Lockbox: MCO 865346 < Previous Transaction ONE GEICO CENTER MACON, GA 3.1296_0001 Batch Summary Transaction 35 Continued Transaction Total: $893.04 Deposit Account 4i32991530 Detailed Payment Summary Next Transaclion > Deposit Date: 11/12020 NO. N 219327211 Date: 11/09/2020. _ , . GEICO GENERAL INSURAN Field Ctaim Center b8itorida CE CO 8 I Claimant Name: Samanlha Kohlman losured Narne: Salnanlha Kohlman . Tax l0 / ss#t )C(-)CO(0531- AttyADJ Co!e: , , " AdjusterCode: NM35 cr"i, *, OSsi]76oa9ob0oooi Oate of Loss: 09/2112020 TotalAmounti s*-893.04 Payment Type: . LOSS , ' ffi Browad Sheriffs Fire Rescue PO Bcx 865346 Ortando FI 32886-5346 IPAND FEATURE AND AIT,IOUNT 01 NBM $*893.04 Item 2 Frcnt lmag€ Page 85 ol 108 P.y To: Broward SheriffsHre Ra;c,j: : " ln Paymentof .- -: Pelsooat tnju.y'pdtedioi. _. .,. ',.., ll .. Acct#:585!7821 , " _" - : .,. '.i o9s;.9srz1zo,zo!9drlozo r ..'. .,^' " . _". m : t" " --)::-';';'"iro.!o, -...-'", .."--"' H+ Now, parties invotved in a cEtcoctaim "u, il;i. il;;;gr"ss of rhe ctaim, view damageHf photos and more at qeico.com*GErco poricyhord"rJ """n ,-u-ii u p"vment, change drivers or** vehibres and rsquesi additionar cr""r"s;".:- rt:;ain:;;;;iii'Gi,"o, 15 minutes courd savd #liffiffi-:nlarinsurance- 9r;""51.yi,3;',..1i"."u"ii"or"ro"pori"y;;;rr#;;;;; ' .: mese ohiine iervices are unavaitadt6 ionssigi;i ii* joii"ynora"r" and iJinrircia, pr,*no,oo" clf,*h.k PLEASE oEIACHANO kEEp FOR YOUR RECOROS ililtilililililililffl[ 610022620569 2020-1 1 -13 1 1 :49:1 6 861 0022620569 Batch: 524 Lockbox: MCO 865346 < Previous Transaction Next Transaclion > DeDosit Date: 1 1/'122020 GEtCO.gclco.coltt EOR #: cF9677247 EXPLANATION OF REVIEW 3 8 c I g Ftoida | 10t14t2020 : aRoWARO SHERTFFS FIRE RESCUE : 059076049000000 i tAq21t2o2g :KOHLMAN, SAMANTHA 2601 W BROWARD ALVD Fo.t taudcrdate, FL 33312 : BROWARD SHERIFFS F|RE RESCUE 18385 NE3fiH CT North Mlamt Beach, FL 33160_520 P.Iienr AccouDt S :58537a21 Adlu.t r Nahe :carfieStOnge 5950C0534 PO Box 885346 Orland,c, FL 32BOe5 i 09n1n0m - O9n1DO2O :GEICO PO 3ox 9091 Macon, G,\3120e-9091 ffi ffi G99.11 AcLte pa h du6 to trauoa Need for continuous 3upeMsjon LINE DOS neoucrror ".ou"ff[ o[f,o"vj$! exet"ur., SH Gr@nd nitBsoFrrraure m[e l/t.O 5293.44 3ao 03 !c@ a2L36 t21E 1.0 tr, t.z 32oa 7s $0.0o t9(}294 72tE 11,.105.16 S23a 36 $ooo 51,!t6.3o ReimhrBehent Amounl : t PEvlrus R.imbqrs.menr Amount : t Oifer.nce io R.imbor.Em.ntAoounr : t Apponb.m.nt Amount : t L€ss oeduc{bte : a Lihited aer.tirr/Copay : t EoRch.ctAmounl: t 'r'tr6.30 0.00 0.00 o.o0 0.@ 0.00 893.0/t Back lmage Page 86 of 108 Batfi Summary TransacUon 35 Continued Transaclion Total: 5893.04 Deposit Account: 4,l3299'1530 2 Ogt2lb AUA gl Tlack your m.dic€tclaims submitted loGEtco by en.ouing in ouron ne Medicatpmvider Ctajm Trackiflq welEite arrhtlps://padnels. geico.cofl ]/mpclweb. Forquestions r.gerding payment and this EoR. please ca,t yourGEIco adJ.usler carlie st onge at 6€3619-4601 x4501 UNITED I{EALTHCARE INSUXANCE CO!.IPANY ATLANTA, GA ]03?{ O 3OO COUNTY OE BROIARD OFEICE OF IH ?o Box 8653a6 oRInNm, FL 128t6 EIN: CHECK DAIE: CHECK ATT: PRODUCTION DATE 595000534 t437252565 o3/at/202t o!/at/2o2r POS NOS PROC UOoS BILIED ALLO1IED DEDUC! COINS GR?/RC.AIT NAI'1E : KOHLMAN, SAI,IANTI{A al 1 ACNT : X5351?321A0 cw sEaEus:1 xRN: GR!/mL rJUX, 75271] 0921 092120 o92t 092720 ?r RESP 0.00 SH SH SOB TqTALS IIIIERESA O.OO 1111.72 1l1l,72 0.00 0.OO291.41 291.4a 0.00 0,00 1405.16 1405.16 0.00 0.00 I.ATE FIIING CTIARGE O.OO L r11. r2 293.44 NET L{ O5 - 16 t 1405.15 DEDUCI A]'A 0.00 1405.15 2103.30 GLSSARY : Adj u stmen! , cloup, Reason, l,lOA, and ReErk codea Page 1