Provider Claims Statements Page 1 of 3

Pack# 9111(Network) Date: 11/11/2021 5:59:00PM

Sep claims 2021 NIC
Provider: P1708-Isra Dauod Pharmacy Curr: SP-Syrian Pound
Payer: 41 National Insurance Company

Reference Patient Policy# Date Claimed Amnt Total Approved Payer Share

PM-8913541
‫يحيى جبيلي‬ 308144 23054 12/08/2021 15,000.00 9,000.00 9,000.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.6939 IBUSIMOL 100 ML SYR 1 1 2,000.00 2,000.00

PM.686 DE-VOMIT 8 MG 100 ML SYR 1 1 1,900.00 1,900.00

PM.5790 ZEDNAD 250 MG 50 ML SUSP 1 1 5,100.00 5,100.00

PM.7496 ROCIFLEX - PLUSS 750 1 VIAL 4 0 6,000.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM-8918302
‫ريحانه حسن‬ 181907 23054 21/09/2021 6,400.00 6,400.00 6,400.00

PM-8919997
‫علي عبد ا‬ 272300 23054 19/08/2021 15,800.00 14,300.00 14,300.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.5137 OMNI 300 MG 10 TAB 1 1 4,200.00 4,200.00

PM.9453 NEW-AID 100 MG 30 TAB 1 0 1,500.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.8856 LUKAST LC ADULT 30 TAB 1 1 5,700.00 5,700.00

PM.6549 NASACLEAR 15 ML NASAL SPRAY 1 1 2,200.00 2,200.00

PM.6811 RHINOCORT NASAL SPRAY 1 1 2,200.00 2,200.00

PM-8921133
‫ريحانه حسن‬ 181907 23054 21/08/2021 9,100.00 5,000.00 5,000.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.8366 BROMONASE FORT 30 TAB 1 0 2,500.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.220 PROFLUCAN 200 MG 10 CAP 1 1 3,700.00 3,700.00

PM.8095 MICOPROGEL- FORT 7 OVULES 1 1 1,300.00 1,300.00

PM.7124 AGILOMOX 20 TAB 1 0 1,600.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM-8947345
‫ديمه احمد‬ 243351 23054 09/09/2021 21,700.00 10,700.00 10,700.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.7497 ROCIFLEX - PLUSS 1500 1 VIAL 4 0 8,400.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.6941 CEFIX 400 MG 10 CAP 1 1 5,600.00 5,600.00

PM.7279 DELASTOM 30 MG 24 CAP 1 0 2,600.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.8359 COMBITRUST 20 CAP 1 1 2,300.00 2,300.00

PM.2142 DOLOBUSCOMED 20 TAB 1 1 2,800.00 2,800.00

PM-8947888
‫يحيى جبيلي‬ 308144 23054 09/09/2021 9,650.00 9,650.00 9,650.00
 Provider Claims Statements Page 2 of 3

Pack# 9111(Network) Date: 11/11/2021 5:59:00PM

Sep claims 2021 NIC
Provider: P1708-Isra Dauod Pharmacy Curr: SP-Syrian Pound
Payer: 41 National Insurance Company

Reference Patient Policy# Date Claimed Amnt Total Approved Payer Share

PM-8949127
‫نايا جبيلي‬ 273849 23054 12/09/2021 16,200.00 10,800.00 10,800.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.9439 PRODOL PLUS-K 20 TAB 3 0 5,400.00 0.00 Refer to the adjustment note below

PM.5790 ZEDNAD 250 MG 50 ML SUSP 1 1 5,100.00 5,100.00

PM.4029 BEN-U-RON 100 ml susp 1 1 1,900.00 1,900.00

PM.807 PROSPAN 100 ML SYR 1 1 3,800.00 3,800.00

PM-8950010
‫اسعد جبيلي‬ 269052 23054 13/09/2021 14,100.00 11,400.00 11,400.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.7524 AZOMOND 200 MG 10 TAB 1 1 900.00 900.00

PM.7474 COXIBET 90 MG 20 TAB 1 0 2,700.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.5791 ZEDNAD 500 MG 10 TAB 1 1 5,200.00 5,200.00

PM.8508 BUSCOLD PLUS 20 TAB 1 1 2,800.00 2,800.00

PM.8978 UNEX 30 TAB 1 1 2,500.00 2,500.00

8 claim(s) Total 107,950.00 77,250.00 77,250.00

 Provider Claims Statements Page 3 of 3

Pack# 9111(Network) Date: 11/11/2021 5:59:00PM

Sep claims 2021 NIC

Provider Payer Payment Claimed Approved Payer

Code Due date Curr Amount Amount Share

P1708-Isra Dauod Pharmacy 41 11/12/2021 SP 8 107,950.00 77,250.00 77,250.00

Pay To: BEMO Jableh 0369062 Isra Asaad Dauod

Grand Total by Currency SP 8 107,950.00 77,250.00 77,250.00