Selected Claim

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Claim Recap

Selected Claim
Status	Finalized		Amount Allowed by Plan	$37.79
Claim Number	00001585		PPO Discount	$41.21
Patient Name	DANIEL		Amount not payable: (ineligible amounts)	$0.00
Date of Service(s)	19-Dec-1999 to 19-Dec-1999		Non-Covered Plan Benefits: (Cosmetic, infertility etc.)	$0.00
Claim Type	MEDICAL		Deductible	$0.00
Total Charges	$79.00		Copayment	$20.00
Primary Carrier Payment: (COB)	$0.00

Payment Check Number   00061440 Date of Check Mailed 15-Jan- 2000 In the Amount of: $17.79 Withhold Amount: $0.00 Patient Owes: $20.00

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