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  • Breakdown Platinum Vezeeta Ref-01

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    Naglaa Hassan
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    This document contains medical claim data for two patients with details on the insurer, services rendered, costs, approvals and payments. It shows that for a patient named Sayed Samah, a claim of 905 EGP was submitted, approved and paid for outpatient services at Dar El Fouad Hospital. It also shows a claim of 277.75 EGP was submitted, approved and paid for a patient named Mohamed Abdelmonem Eslam for outpatient services at Ibn Sina Specialized Hospital. Both claims were with the Platinum Vezeeta insurer and settled without penalties or discounts.

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    This document contains medical claim data for two patients with details on the insurer, services rendered, costs, approvals and payments. It shows that for a patient named Sayed Samah, a claim of 905 EGP was submitted, approved and paid for outpatient services at Dar El Fouad Hospital. It also shows a claim of 277.75 EGP was submitted, approved and paid for a patient named Mohamed Abdelmonem Eslam for outpatient services at Ibn Sina Specialized Hospital. Both claims were with the Platinum Vezeeta insurer and settled without penalties or discounts.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
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    32 views24 pages

    Breakdown Platinum Vezeeta Ref-01

    Uploaded by

    Naglaa Hassan
    This document contains medical claim data for two patients with details on the insurer, services rendered, costs, approvals and payments. It shows that for a patient named Sayed Samah, a claim of 905 EGP was submitted, approved and paid for outpatient services at Dar El Fouad Hospital. It also shows a claim of 277.75 EGP was submitted, approved and paid for a patient named Mohamed Abdelmonem Eslam for outpatient services at Ibn Sina Specialized Hospital. Both claims were with the Platinum Vezeeta insurer and settled without penalties or discounts.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 24

    descreptiocode Insurer Curency Admission Date FOB

    4 ‫خدمات العيادات الخارجيه‬


    Platinum Vezeeta EGP 29-May-21 Out-Patient
    4 ‫خدمات العيادات الخارجيه‬
    Platinum Vezeeta EGP 4-Apr-21 Out-Patient
    Master Contract Name Policy Name Policy Number Health Authority Provider Type
    Vezeeta-10 Vezeeta-10 12 Hospital
    Vezeeta-4 Vezeeta-4 4 Hospital
    Provider Name External Ref Asoap Plan ID Invoice # Staff Number
    Dar El Fouad Hospital. October 7685530 1 1 527
    Ibn Sina Specialized Hospital - Giza 1231150630 1 1 172
    Patient Name Card Number Regulator MemberID P.O.ID
    Sayed Samah 088C-EBC9-4CFB-8D80 445777/2021
    Mohamed Abdelmonem Eslam F8F0-9A2B-7BEB-A137 437363/2021
    TransactionID Status Prf.PO.ID FOC Specific Assessment
    457671 Settled Physical Illness 789.00 Abdominal pain, unspecified site
    448922 Settled Physical Illness 466.0 Acute Bronchitis
    Est.Cost Claimed Approved B.Share Denied Discount Other Discounts Provider professional
    905 905 905 0 0 0 0 905 0
    277.75 277.75 277.75 0 0 0 0 277.75 0
    USD In Local BC.Share SettledDate ProfSettledDate ProcessedDate POValidationDate
    57.94 905 0 23-Aug-21 N/A 14-Jul-21 14-Jul-21
    17.78 277.75 0 18-Jul-21 N/A 19-Jun-21 19-Jun-21
    Reimbursement Declined PreValidation DueDate ReceivedDate DeclarationDate
    No No 9-Jul-21 15-Jul-21 15-Jun-21 29-May-21
    No No 11-Jun-21 24-Jun-21 25-May-21 4-Apr-21
    DisChargeDate DeliveryDate ProviderShequeSent ProfChequeSent Product Product Class
    29-May-21 28-Jul-21 23-Aug-21 N/A Vezeeta A A
    4-Apr-21 28-Jul-21 18-Jul-21 N/A Vezeeta A A
    Batch ID Cheque Number Principal Frist Name Principal Family Name DOB Nationality
    420304 9085 Samah Sayed 23-Mar-97 Egypt
    413926 8973 Eslam Mohamed Abdelmonem 31-Oct-92 Egypt
    PreValidation Date Beneficiary Pin Secondary Ref# Processing Note Medical Note NotUsed
    9-Jul-21 No
    11-Jun-21 No
    Pending Contract Type CreationDate NotCoveredCharges CorrectionAmount Pure Claim Value
    0 Group 14-Jul-21 0 0 905.00
    0 Group 4-Apr-21 0 0 277.75
    1,182.75
    Pure Claim Value in Loc Curr Net Claim Value Requested DRG Code Approved DRG Code
    905 905
    277.75 277.75
    Billed DRG Code Paid DRG Code claim Source Reconciled Validated Gender
    Back Office yes Female
    Pre-Certification yes Male
    Professional Name Declined Reason Request Estimation cost Department Admission Month
    905 May-21
    277.75 Apr-21
    Discharge Month Patient File Number Dependency
    May-21 Principal
    Apr-21 Principal
    Authorization Note

    ßÔÝ ØæÇÑÆ ãÚ Úãá ÇáÇÌÑÇÁÇÊ ÇáØÇÑÆÉ ÝÞØ ááãÑíÖ , ãÚ ÇáÑÌæÚ Çáí äßÓÊßíÑ ÇÐÇ ÊÚÏÊ ÇáÊßáÝÉ 500
    Penalty Invoice Amount Policy Inception Date Expiry Date Claim Key Last Update Date
    0 905 17-Apr-21 17-Apr-22 879098-1-1 7/27/2021 16:07
    0 277.75 6-Mar-21 6-Mar-22 836539-1-1 7/11/2021 17:40
    Is Electronic Batch Label Marital Status Precert Last User
    No 107324-MAY-21-PLT V-1/22 Married Romaissa Mohamed
    No 115161 - Apr. 21 - PLT.V-1/10 Married Romaissa Mohamed
    Processing By User Created by User ER LOS Prescribed LOS Approved EOC Flag
    Romaissa Mohamed Romaissa Mohamed No 0 0 No
    Romaissa Mohamed Omar Fathy Sayed Aly No 0 0 No
    EOC Key EOC Status Club Claim Status Total Early Payment Discount Priority Payer Share
    0 0
    0 0
    Originating Provider Name Agreement Classification Payer Share Tax Syndicate Nbr
    General Network (GN) 0
    Restricted Network 0
    Payer Share Without Tax Non-Network Provider Resubmitted ResubmittedFrom From Currency
    905 No No
    277.75 No No
    Exchange Rate Batch Validation Date Batch Creation Date
    0 14-Jul-21 24-Jun-21
    0 19-Jun-21 3-Jun-21

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