Claims Summary
By Group Code Report Date: 01/08/2004 By Plan Report Period: 09/01/2003 - 09/30/2003 Paid By Location
	Claims	Charges	Disallowed	Allowable	PPO-Disc	Deduct	CO-Pays	Coins OOP	COB-Reimb	COB-Sav	Other	Paid
Group: 99999
Benefit Type: D
	22	$7,330.00	$605.40	$6,724.60	$.00	$200.00	$.00	$1,156.40	$.00	$.00	$.00	$5,368.20
Total Ben Type: D	22	$7,330.00	$605.40	$6,724.60	$.00	$200.00	$.00	$1,156.40	$.00	$.00	$.00	$5,368.20
Benefit Type: M
	136	$130,895.23	$49,457.33	$81,437.90	$29,000.26	$1,798.40	$690.00	$2,583.70	$.00	$.00	$.00	$47,365.54
Total Ben Type: M	136	$130,895.23	$49,457.33	$81,437.90	$29,000.26	$1,798.40	$690.00	$2,583.70	$.00	$.00	$.00	$47,365.54
Benefit Type: P
	3	$12,194.62	$.00	$12,194.62	$.00	$.00	$.00	$.00	$.00	$.00	$.00	$12,194.62
Total Ben Type: P	3	$12,194.62	$.00	$12,194.62	$.00	$.00	$.00	$.00	$.00	$.00	$.00	$12,194.62
Total Group: 99999	161	$150,419.85	$50,062.73	$100,357.12	$29,000.26	$1,998.40	$690.00	$3,740.10	$.00	$.00	$.00	$64,928.36
	Claims	Charges	Disallowed	Allowable	PPO-Disc	Deduct	CO-Pays	Coins OOP	COB-Reimb	COB-Sav	Other	Paid
TOTAL	161	$150,419.85	$50,062.73	$100,357.12	$29,000.26	$1,998.40	$690.00	$3,740.10	$.00	$.00	$.00	$64,928.36
Claim Summary Requestor: John Employer Report Date: 01/08/2004 Sort fields: Selected values: Group 99999 Benefit Type(s): ALL Date: Paid Report Period: 09/01/2003 - 09/30/2003