Claim Detail

Understanding Your Claim     

Member ID: *********Claim Number:11111111100
Patient DOB:01/01/19XXStatus: Processed
Patient Acct. No.999999999999999 Processed Date:08/16/2005
Provider Date of Service Total Charges Not Covered Note Balance of Covered Charges Applied
Allowable Deductible Copay/Coinsurance Benefit
ABC MEDICAL CTR07/25/2005 86.640.00 HV 86.64 0.000.00 17.33
             
 Totals 86.640.00  86.64 0.000.00 17.33
Notes
HV PROVIDER ACCEPTS MEDICARE'S APPROVED AMOUNT AS CHARGE. DO NOT SUBMIT A
PAPER CLAIM FOR THIS PATIENT-ELECTRONICALLY SUBMITTED FROM MEDICARE.
 
 
 
 
 
 
 
 
 
 
 
 
Summary
Benefits Payable17.33
Paid by Other Plan69.31
Other Plan Paid Adjustment-69.31
Other Adjustment0.00
Other Adjustment Reason 
Total Paid by GEHA17.33
Patient Responsibility0.00

PayeeCheck # Amount
JOHN DOE000000000.00
ABC MEDICAL CTR98745617.33