Document GmbmRjDz8eVw48YrEOOJ2eZ3r
Painesville, Ohio June 20, 1991
TO: Joe Carroza 2-33A
FROM:
Marc Werbach
SUBJECT: ______________
Workers' Comp Case #90-13
Claim No. 0D43248-22
Metropolitan
Insurance
has paid bills
totaling
$26,313.00 to providers of services under the wage medical
plan for
Since this claim has recently been accepted as a Workers' Compensation liability, I am requesting that we reimburse Metropolitan Life Insurance Company for the $26,313.60 and charge our Workers' Compensation account.
MAW:rahh cc: D. F. Muccino 1-1
Russell Jackson - OBWC W.C. File RMS JJP
UNIR0000967
;e of Service Provider ci Service
10/1-23/90 15/09/90 10/12/90
10/12/90 10/15/90 10/15/90 10/15/90 10/16/90 10/16/90 10/15/90 10/16/90
10/16/90 10/19/90 10/20/90 10/20/90
10/22/90
10/25-29/90 10/25-11/10/90
10/26/90 10/28-11/6/90
10/30/90 11/08/90 11/10/90 11/10/90
Va. rletcher, H.D. late 5cs?iu! System
Drs. dill Tboaas
Lake Medical Center
Drs. Sill s Thonas
Drs. Bill 5 Tboaas
Drs. Sill 5 Thoaes
Lake Hospital Systea
Hillcrest Hospital
Lake Medical Center
Lake Medical Center
Drs. Hill 6 Cbapnick
Lake Medical Center
Lake Medical Center
Drs. Kill S Thoaas
Lake Medical Center
University Surgeons
University Hospital
University Otolaryngoloty
University Radiology
Cleveland Physicians
University Physicians
Physicians' imbalance
Geneva Memorial Hospital
Total
?d. by Met to ?d. by Met to Paid by Provider
180.00 10.70 154.00
300.00 323.00 126.00 25.00 784.00 160.00 289.80 933.60 160.00 76.40 168.00 77.00 174.00 375.00 21,218.70 115.00. 552.00 135.00 125.00 385.40 498.63
27,357.23
0.00 10.70 154.00 300.00 323100 126.00 25.00 784.00 160.00 289.80 933;SO 160.00 76>'40 168.00 77.00 174:00 150.00 2H170.70
20i:37 j; 20*00 125;00
ll||fe
32.00 35.00
.180.00 j
--.92.GO1 288.50 1
23.00
684.50
58.00
Co-lnsaranc Amount Balance
148.00 113.00
45.00
23.00 72.13 23.00
.225.00 42.00 115.00
360.27
311.13 861.57
'T - - ........... }
| Paid by Metropolitan to Provider
Paid by Metropolitan to
^ Paid by Metropolitan to
Paid by
to provider (co-insurance amount)
In process of payment locally
UNIR0000968