30/01/2020

Explanation of Benefits
Risk Carrier : TE Data Policy Holder Name : TE-DATA
Member : 50008906 50454122 Staff # : TEDATA-3927-E Provider : Mohamed Mahmoud El Sokary
Claim Number :
MCN : 28160143 Batch # : 0
Principal Name : ‫ﻑ ﻳﻮﻧﺲ ﻳﻮﻧﺲ‬
Name : ‫ﻳﻮﻧﺲ ﻳﻮﻧﺲ‬
Date Of Birth : 1988

Transaction Date : 30/01/2020 Invoice Number : Physician : Mohamed El Sokary

Diagnosis : Dental caries, unspecified Approved by Karim Mohamed

Detailed Bill Med File : Cons. Fees : 0.00 EGP SSNBR : 35612281

Service Item Unit Price Type Qty Claimed Curr Total Claimed Qty Appr. Total Appr. Disc.

Restorative dentistry 1- ‫ ﺣﺸﻮ ﻛﻤﺒﻮﺯﻳﺖ ﻟﻠﺴﻨﺔ ﺭﻗﻢ‬14 200.000 1 EGP 200.000 1 200.000 0.000

2- ‫ ﺣﺸﻮ ﻛﻤﺒﻮﺯﻳﺖ ﻟﻠﺴﻨﺔ ﺭﻗﻢ‬15 200.000 1 EGP 200.000 1 200.000 0.000

3- ‫ ﺣﺸﻮ ﻛﻤﺒﻮﺯﻳﺖ ﻟﻠﺴﻨﺔ ﺭﻗﻢ‬44 200.000 1 EGP 200.000 1 200.000 0.000

4- ‫ ﺣﺸﻮ ﻛﻤﺒﻮﺯﻳﺖ ﻟﻠﺴﻨﺔ ﺭﻗﻢ‬45 200.000 1 EGP 200.000 1 200.000 0.000

Summary Patient Share

Total Claimed 800.000 EGP Co-Insurance 0.000 EGP
Total Approved 800.000 EGP Exceeding Limitation 0.000 EGP
Discount 0.000 EGP Uncovered Items 0.000 EGP

Net Amount 800.000 EGP Total Patient Share 0.000 EGP

The claims will be subject to review and audit based on the Tariff, Discounts and Medical Necessity (Usual, Reasonable and Customary), on case by case basis. Thank You. Page 1 of 1