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& soo <br />May 23, 2017 <br />Stephen Cox <br />Fire Chief <br />South Bend Fire Department/EMS <br />1222 S. Michigan Street <br />South Bend, IN 46601 <br />Eric Holcomb, Governor <br />State of Indiana <br />Indiana Health Coverage Programs <br />www.indianamedicaid.com <br />MYERS AND STAUFFER LC <br />9265 COUNSELORS ROW, SUITE 100 <br />INDIANAPOLIS, IN 46240 <br />800.877.6927 1 317, 846, 9521 <br />www.msfc.com/Indiana <br />RE: 201.4 Governmental Ambulance Payment Adjustment for Managed Care Services <br />UPS Tracking Number— I 9V1 W32 03 9301 3094 <br />Provider Name: South Bend Fire Department/EMS <br />Provider Number: 100286930A <br />NOTICE OF PROGRAM REIMBURSEMENT <br />This letter is the Office of Medicaid Policy and Planning's Notice of Program Reimbursement (NPR) of <br />your facility's Indiana Medicaid Governmental Ambulance Payment Adjustment for Medicaid managed <br />care ambulance services for calendar year 2014. <br />This payment adjustment was calculated based on your facility's submitted cost report for fiscal year <br />ended December 31, 2014 and Medicaid managed care claims for services incurred during calendar year <br />2014. <br />FINAL ORDER <br />The Indiana Medicaid Governmental Ambulance Payment Adjustment for Medicaid managed care <br />ambulance services for calendar year 2014 is $1,411,931.47. <br />The intergovernmental transfer (IGT) amount is $471,088.31. <br />If you are in agreement with this payment, upon receipt of this letter, please submit the following <br />information to the address below no later than fifteen (15) days of your receipt of this letter: a cover letter, <br />a copy of this payment letter, the signed Payment Agreement (enclosed with this letter), and the <br />Intergovernmental transfer check in the amount of $471,088.31 made payable to the Treasurer of the <br />State of Indiana. We recommend submitting these documents in a manner through which delivery can <br />be confirmed, such as hand delivery, courier, United States Post Service certified mail, United Parcel <br />Service, or Federal Express. <br />Indiana Family and Social Services Administration <br />13992 Collections Center Drive <br />Chicago, 1L 60693 <br />Kµ u s o <br />Children's Health Insurance Program Healthy Indiana Plan Hoosier Care Connect " F <br />Hoosier Healthwise • M.E.Q. Works , Traditional Medicaid"'`: ^ <br />