Claim Information
Claim ID CLM-2024-000001
Service Date 2024-01-16
Service Type Consultation
Priority Urgent
Amount $2,200.00
Status Pending
Doctor Dr. Mohammed Al-Ahmad
Created On 2024-01-16 10:30:00
Last Updated 2024-01-16 14:45:00
Next Steps
Status Ready for Submission
Action Required Submit claim to insurance provider
Patient Name: Fatima Abdullah Al-Saad
Patient ID: PAT-0001
National ID: 1234567890
Date of Birth: 1990-01-01
Attending Doctor: Dr. Mohammed Al-Ahmad
Service Type: Consultation
Service Date: 2024-01-16
Department: General Medicine
Visit Type: Outpatient
Primary Diagnosis: General Consultation
ICD-10 Code: Z00.00
Procedure Code: 99213
Medical Notes:
Patient consultation and examination.
Insurance Provider: Cooperative Insurance Company
Policy Number: POL-00000001
Insurance Card Number: INS-0000000001
Coverage Percentage: 80%
Deductible Amount: $500.00
Co-payment: $50.00
Authorization Number: AUTH-000001
Policy Holder: Fatima Abdullah Al-Saad
Total Charges: $2,200.00
Insurance Coverage: $1,760.00
Patient Responsibility: $440.00
Deductible Applied: $500.00
Co-payment: $50.00
Co-insurance: $390.00
NPHIES Reference ID: NPH-00000001
Provider ID: PROV-000001
Eligibility Status: Eligible
Submission Method: Electronic (EDI)
Submission Deadline: 2024-02-15
NPHIES Compliant: Yes
Special Instructions:
Please process this claim according to standard procedures.