Disallowed
By Group Code Report Date: 11/04/2003 By Plan Report Period: 10/01/2003 - 10/31/2003 Paid By Location
	Additional Info. Required	Claim Edit Rules	Duplicate Charges	Ineligible Members	Plan Limits/ Maximums (Non-Covrd)	U & C Reduction	Other	Total
Group: 99999
Benefit Type: D
	$187.00	$.00	$.00	$.00	$299.40	$119.00	$.00	$605.40
Total Ben Type: D	$187.00	$.00	$.00	$.00	$299.40	$119.00	$.00	$605.40
Benefit Type: M
	$26,351.95	$550.50	$21,758.46	$.00	$.00	$.00	$796.42	$49,457.33
Total Ben Type: M	$26,351.95	$550.50	$21,758.46	$.00	$.00	$.00	$796.42	$49,457.33
Total Group: 99999	$26,538.95	$550.50	$21,758.46	$.00	$299.40	$119.00	$796.42	$50,062.73
	Additional Info. Required	Claim Edit Rules	Duplicate Charges	Ineligible Members	Plan Limits/ Maximums (Non-Covrd)	U & C Reduction	Other	Total
TOTAL	$26,538.95	$550.50	$21,758.46	$.00	$299.40	$119.00	$796.42	$50,062.73
Disallowed Requestor: John Employer Report Date: 11/04/2003 Sort fields: Selected values: Group 99999 Benefit Type ALL Date: Paid Report Period: 10/01/2003 - 10/31/2003