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Claim Detail
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Selected Claim |  |
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| LAHOUSE | |||||||||
| PHYSICIAN/CLINIC VISIT | 03 Feb 2003 to 03 Feb 2003 | ||||||||
| Total Charge | PPO Adjustment | Ineligible Amount | Remark Code | Co-pay | Amount Allowed | Deductible Amount | Other Carrier Payment | Co-Insurance | Payable Benefit |
| $76.00 | $22.00 | $22.00 | PE | $0.00 | $0.00 | $54.00 | $0.00 | 80.0 % | $0.00 |
| LAHOUSE | |||||||||
| LABORATORY SERVICES | 03 Feb 2003 to 03 Feb 2003 | ||||||||
| Total Charge | PPO Adjustment | Ineligible Amount | Remark Code | Co-pay | Amount Allowed | Deductible Amount | Other Carrier Payment | Co-Insurance | Payable Benefit |
| $16.00 | $7.00 | $7.00 | PE | $0.00 | $0.00 | $9.00 | $0.00 | 80.0 % | $0.00 |
| LAHOUSE | |||||||||
| LABORATORY SERVICES | 03 Feb 2003 to 03 Feb 2003 | ||||||||
| Total Charge | PPO Adjustment | Ineligible Amount | Remark Code | Co-pay | Amount Allowed | Deductible Amount | Other Carrier Payment | Co-Insurance | Payable Benefit |
| $116.00 | $105.00 | $105.00 | PE | $0.00 | $0.00 | $11.00 | $0.00 | 80.0 % | $0.00 |
| LAHOUSE | |||||||||
| LABORATORY SERVICES | 03 Feb 2003 to 03 Feb 2003 | ||||||||
| Total Charge | PPO Adjustment | Ineligible Amount | Remark Code | Co-pay | Amount Allowed | Deductible Amount | Other Carrier Payment | Co-Insurance | Payable Benefit |
| $38.00 | $18.00 | $18.00 | PE | $0.00 | $0.00 | $20.00 | $0.00 | 80.0 % | $0.00 |
| LAHOUSE | |||||||||
| LABORATORY SERVICES | 03 Feb 2003 to 03 Feb 2003 | ||||||||
| Total Charge | PPO Adjustment | Ineligible Amount | Remark Code | Co-pay | Amount Allowed | Deductible Amount | Other Carrier Payment | Co-Insurance | Payable Benefit |
| $38.00 | $19.00 | $19.00 | PE | $0.00 | $0.00 | $19.00 | $0.00 | 80.0 % | $0.00 |
| LAHOUSE | |||||||||
| LABORATORY SERVICES | 03 Feb 2003 to 03 Feb 2003 | ||||||||
| Total Charge | PPO Adjustment | Ineligible Amount | Remark Code | Co-pay | Amount Allowed | Deductible Amount | Other Carrier Payment | Co-Insurance | Payable Benefit |
| $36.00 | $16.00 | $16.00 | PE | $0.00 | $0.00 | $20.00 | $0.00 | 80.0 % | $0.00 |
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Totals | |
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| Total Charge | PPO Adjustment | Ineligible Amount | Remark Code | Co-pay | Amt Allowed | Deductible Amount | Other Carrier Payment | Co-Insurance | Payable Benefit |
| $320.00 | $187.00 | $187.00 | N/A | $0.00 | $0.00 | $133.00 | $0.00 | N/A | $0.00 |
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