HomeMy WebLinkAboutInv# 22024200002676 - Blue Cross and Blue Shield of Florida - 05/01/2023MANUAL REFUND REQUEST FORM
TO: FINANCE DEPARTMENT OI BROWARD SHERIFFS FIRE RESCUE
BETOW REPRESTNTS A REOUEST FOR YOUR ORGANIZATION TO ISSUT A REFUND FOR THE
FOLLOWING ACCOUNT. THE REFUND CHTCK MUST BE ISSUED TO THE PAYOR,/PATIENT SHOWN
BTLOW, PLEASE CONTACT CTIENT RTLATIONS SHOUTD YOU NEED FURTHER INFORMATION,
REFUND DETAII.S:
PATIENT ACCOUNTC 64149638
DATE OF 5E RVICE 4124/2O2?
PATIENT NAME DE N I5E M. REED
REFUND AMOUNT: S455.26
REFUND REASON OVERPAYMENT: OTHER INSURANCE PAID
INSURANCE CLAIM fl: H 100000980332067
REFUND PAYABLE TO:
NAME:
ADDRESS
CITY, sTATE ZIP
BLUE CROSS AND BLUE SHIELD OF FLORIDA
DEPT. 1213
PO BOX 121213
ADDITIONAI. INFORMATION
DALLAS, TX 75312
Broward Sheriffs Fire Rescue
PO Box 865346
Orlando. FL 32886-5346
Account #
64149638
Reed. Denise
1025 SE 3RD AV
405
DANIA FL 33004
Pa
Patient
Total Charges
$13',t2.14
ment to EMS - Prima lnsurance
Total Payments
$'t 180.92
Ass ig n/Adju st
$0.00
Itemized Statement
Itemized Charqes
Amou ntDescriptionUnit Cost
ALS1 Emeroencv Bass Rate Dania 1225 66 1 12?5.66
21 .62 4 86.48ALS Emerqency Mileaqe Dania
Account Detail
Scan #Post Date AmountTransaction
ps1954263 oa-30-2022 455.26Payment to EMS - Primary lnsurance
r165894'1070637 07 -28-2022 1180.92
10-25-2022 -455.26Pavment to EMS - Pnmary lnsurance 14857 5440',|
Account Summary
Balance Oue
$131.22
I
Trip
Date of Service: 04-24-2022
lncident #:: FDN22042400002676
Pickup: '1025 SE 3RD AV # 405
Destination: MEMORIAL REGIONAL HOSPITAL
Un its
FlaldaAhe @@
An indep€ndent Licensee of lhe
Elue Crors and Blue Shield AJsociation
For forms with attached checks. please mail to:
Blue Cross and Blue Shield of Florida
Dept. l2l3
PO Bor l212l3
Drllss, TX 75312- l2l-1
OR Express Courier Service (e.g., oHL., FedEx')
Blue Cross Blue Shicld of Florida
Lock Bor tl9l2l3
l50l North Plano Rd
Richardson. TX 750t1I
For forms without checks,
please mail to:
Florida Blue
P.O. Bor 1798
Jacksonrille, Fl, .122-ll
Claim Overpayment Refund Form
Overpayment refunds will go directly to a secured bank lock box to marntarn the accuracy and timeliness
of applying refund checks.
1. Provider Name County of Broward Offic( BCBSF lnvoice Number
BCBSF Provider Number 40692 Refund Date 1013012022
National Provider ldentifier (NPl) 1p.3t2621 Claim Number H 1 00000980332067
Patient Name oENISE REED Dato(s) of ssrvico 04,12412022
Patient contract Number LAM839003654 claim Paid Date odl3ol2022
2. Reason for Refund (Explain the reason the money is belng returned. )
t/Another carrier also made payment. Attach other carrier EOB.
lncorrect contract number. lncorrect palient contract number
Conect Patient contract number
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Batch:
Lockbox
316
ATL 865346
Transaction 28 Summary
Transaction Total: 1,180.92 USD
DepositAccount: 4132991530
Deposit Date 07 t25t2022
Check 1 Check Amount:
Check Account Number
Check Number:
Front lmage
o7 /L2/2022 $rrrr1,180.92r
*rrone Thousand One Hundred EighEy Dollara,And 92/1oorl*
. coIJNrY oF BRoWARD oFFIcE oF TH +!-\NE..S.. PO BOX 855345- , ^ t t. oRr,ANDcf FL 32886 /t *--fl.nJoru'
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DATE
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PAY TIIIS ANTOI,,NT
wars f/rrco arrl. x-r
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1,180.92 USD
4125316976
7223177
Batch:
Lockbox
316
ATL 865346
f ransaclion 28 Continued
Transaction Total: 1,180.92 USD
DeposrtAccount: 413299'15:X)
Deposrt Date 07 t25t2022
Itsm'l
Front lmage
s Arnadcan llrrltl.r Ottlcfl llarrlcrl PlanE .6&iffitrrl-! *l.ro.rD.
3150 U.9- Ro'n 60
On , WV 256,i5
Americlr l.laricinrc Officera !4cdical Pla-uBenefitE Ad$inisEercd by AJaerlcan Ben.fit Corp.
3150 U. S. RouEe 60
Ona, WV 255a5
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COUNTY OF BROT{ARD OFFICE OF TH
PO BOX 86s346
ORLANDO FL 32886
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