Claim Information
Claim ID CLM-2024-000002
Service Date 2024-01-17
Service Type Laboratory
Priority Medium
Amount $1,500.00
Status Pending
Doctor Dr. Sarah Al-Rashid
Created On 2024-01-17 10:30:00
Last Updated 2024-01-17 14:45:00
Next Steps
Status Ready for Submission
Action Required Submit claim to insurance provider
Patient Name: Ahmed Khalid Al-Mutairi
Patient ID: PAT-0002
National ID: 1234567890
Date of Birth: 1990-01-01
Attending Doctor: Dr. Sarah Al-Rashid
Service Type: Laboratory
Service Date: 2024-01-17
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-00000002
Insurance Card Number: INS-0000000002
Coverage Percentage: 80%
Deductible Amount: $500.00
Co-payment: $50.00
Authorization Number: AUTH-000002
Policy Holder: Ahmed Khalid Al-Mutairi
Total Charges: $1,500.00
Insurance Coverage: $1,200.00
Patient Responsibility: $300.00
Deductible Applied: $500.00
Co-payment: $50.00
Co-insurance: $250.00
NPHIES Reference ID: NPH-00000002
Provider ID: PROV-000002
Eligibility Status: Eligible
Submission Method: Electronic (EDI)
Submission Deadline: 2024-02-16
NPHIES Compliant: Yes
Special Instructions:
Please process this claim according to standard procedures.