Claim Detail

Understanding Your Claim     

Member ID: ********* Claim Number: 11111111100
Patient DOB: 01/01/19XX Status: Processed
Patient Acct. No. 999999999999999 Processed Date: 08/16/2001
Provider Date of Service Total Charges Not Covered Note Balance of Covered Charges Applied
Allowable Deductible Copay/Coinsurance Benefit
ABC MEDICAL CTR07/25/2001 86.640.00 HV 86.64 0.000.00 17.33
             
 Totals 86.640.00  86.64 0.000.00 17.33
Notes
HV PROVIDER ACCEPTS MEDICARE'S APPROVED AMOUNT AS CHARGE. DO NOT SUBMIT A
PAPER CLAIM FOR THIS PATIENT-ELECTRONICALLY SUBMITTED FROM MEDICARE.
 
 
 
 
 
 
 
 
 
 
 
 
Summary
Benefits Payable17.33
Paid by Other Plan69.31
Other Plan Paid Adjustment-69.31
Other Adjustment0.00
Other Adjustment Reason 
Total Paid by GEHA17.33
Patient Responsibility0.00
Payee Check # Amount
JOHN DOE00000000 0.00
ABC MEDICAL CTR 987456 17.33

 

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