Claim CLM-001
Blue Cross Blue Shield · Submitted on 2025-04-15
Active
AB+
Eleanor Pena
Patient ID: P547512
Policy Number
BCBS123456789
Relationship
Self
Group Number
GRP987654321
Location
1901 Thornridge Cir, Shiloh, HI
Claim Information
Insurance claim breakdown
Claim Type
Medical
Claim Amount
$200.00
Approved Amount
$180.00
Patient Responsibility
$20.00
Payment Date
2025-05-15
Net Payable
$180.00
Covered Services
| # | Service | Date | Billed | Allowed | Patient Resp. |
|---|---|---|---|---|---|
| 1 | Urology Services | 2025-04-15 | $802.00 | $839.00 | $832.00 |
| 2 | Gynecology & Women's Health | 2025-04-15 | $4,500.00 | $837.92 | $91.83 |
| 3 | Laboratory Testing | 2025-04-15 | $74.03 | $4,500.00 | $92.93 |
| 4 | Oncology Services | 2025-04-15 | $4,500.00 | $830.92 | $74.03 |
| 5 | Plastic & Reconstructive Surgery | 2025-04-15 | $45.99 | $839.00 | $783.83 |
| 6 | Intensive Care Unit (ICU) | 2025-04-15 | $91.83 | $73.02 | $91.83 |
| 7 | Orthopedic Surgery | 2025-04-15 | $73.02 | $832.00 | $839.00 |
Notes
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