Claim Information
Claim ID CLM-2024-000003
Service Date 2024-01-18
Service Type Pharmacy
Priority Normal
Amount $800.00
Status Pending
Doctor Dr. Khalid Al-Saeed
Created On 2024-01-18 10:30:00
Last Updated 2024-01-18 14:45:00
Next Steps
Status Ready for Submission
Action Required Submit claim to insurance provider
Patient Name: Nora Mohammed Al-Qahtani
Patient ID: PAT-0003
National ID: 1234567890
Date of Birth: 1990-01-01
Attending Doctor: Dr. Khalid Al-Saeed
Service Type: Pharmacy
Service Date: 2024-01-18
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-00000003
Insurance Card Number: INS-0000000003
Coverage Percentage: 80%
Deductible Amount: $500.00
Co-payment: $50.00
Authorization Number: AUTH-000003
Policy Holder: Nora Mohammed Al-Qahtani
Total Charges: $800.00
Insurance Coverage: $640.00
Patient Responsibility: $160.00
Deductible Applied: $500.00
Co-payment: $50.00
Co-insurance: $110.00
NPHIES Reference ID: NPH-00000003
Provider ID: PROV-000003
Eligibility Status: Eligible
Submission Method: Electronic (EDI)
Submission Deadline: 2024-02-17
NPHIES Compliant: Yes
Special Instructions:
Please process this claim according to standard procedures.