Claim number
-
Certificate
-
Service recipient
-
Birth year
-
Paid to
-
Billed amount
-
Deductible
$0.00
Other plan paid
-
Paid amount
-

Claimed expenses

Benefit
Service dates
Benefit year
Coverage percent
Billed amount
Paid amount
Status
Processed date
-
-
-
-
-
-
Queued
Processed
Audited
In process
Awaiting statement from other carriers
-
Fee Guide Year used for calculating the maximum amount that could be paid for this service
-
Service provider
-
Billed dispensing fee
-
Eligible dispensing fee
-
Government paid amount
-
Total eligible amount used to calculate benefit
-
Deductible applied
-
Copay amount
-
Other plan(s) previously paid
-
info

Paid amount explanation

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