CLAIM SETTLEMENT ADVICE

CHAFA, T (MR)
PRIVATE BAG 62
N/A
N/A

Page: 1
Member Number: 123975 Statement Date: 2023-03-09
Plan: EXECUTIVE EXTRA (B) Statement Number: 0012

Date of Tariff Amount Paid to Paid to Rejected Reason Payment

Patient
Service Code Charged Provider Member Amount Codes Date
FAMILY CARE PHARMACY- - 9960222
2023/03/08 ARYA MDSCR P 180.00 P 114.24 P 0.00 P 65.76 2023/03/09
2023/03/08 ARYA MDSCR P 215.00 P 93.45 P 0.00 P 121.55 2023/03/09
2023/03/08 ARYA MDSCR P 83.00 P 38.52 P 0.00 P 44.48 2023/03/09
Total for FAMILY CARE PHARMACY- - 9960222 P 478.00 P 246.21 P 0.00 P 231.79

Grand Total P 478.00 P 246.21 P 0.00 P 231.79

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