AIB Small Group THIS IS NOT A BILL

Zaheeir Ali Summary of a claim for services on September 03,2019

c/o Agostini Insurance Brokers for services provided by Alastair Martin

Claim Detail
Beacon Insurance received claim 09192019JQ 0003 on September 16,2019

Member Name: Zaheeir Ali

Member ID: NUB-00006-00
Service Type of Service Submitted Amount Covered Copay Deductible Net Amount Coinsurance* EOB
Dates Charges Not Amount
Covered
9/3/2019 PERIODIC ORAL EXAMINATION 100.00 0.00 100.00 0.00 100.00 0.00 0.00 606
9/3/2019 PROPHYLAXIS ADULT 600.00 0.00 600.00 0.00 0.00 480.00 120.00 752
9/3/2019 DENTAL BITEWING SINGLE FILM 200.00 0.00 200.00 0.00 0.00 160.00 40.00

Total $900.00 $0.00 $900.00 $0.00 $100.00 $640.00 $160.00

*After you have met your deductible, the cost of covered expenses are shared by you and your health plan.
The percentage of covered expenses you are responsible for is called coinsurance.

EOB Remarks
606 Deductible applied.

752 Premium Not Paid

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