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  • Claim Payment Result: Provider Information

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    This claim payment result document summarizes a payment made to Cheri McDonald for massage therapy services provided to Mary Ann Monteith between August and November 2023. The insured, Mary Ann Monteith, received $475 in massage therapy services from Cheri McDonald, which were all eligible for payment and paid in full by the insurer.

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    Original Title

    2023331V5503 (1)

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    This claim payment result document summarizes a payment made to Cheri McDonald for massage therapy services provided to Mary Ann Monteith between August and November 2023. The insured, Mary Ann Monteith, received $475 in massage therapy services from Cheri McDonald, which were all eligible for payment and paid in full by the insurer.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    7 views1 page

    Claim Payment Result: Provider Information

    Uploaded by

    russett
    This claim payment result document summarizes a payment made to Cheri McDonald for massage therapy services provided to Mary Ann Monteith between August and November 2023. The insured, Mary Ann Monteith, received $475 in massage therapy services from Cheri McDonald, which were all eligible for payment and paid in full by the insurer.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Claim Payment Result

    Transaction Date 27 Nov 2023


    Claim ID 23331-V5503
    Invoice Number

    Provider Information
    Name Cheri McDonald
    Provider Number 12301564

    Insured Information Patient Information


    Policy 00200-000 Identification Number K6946719
    Name MARY ANN MONTEITH Name MARY ANN MONTEITH
    Address 72850 DUCHARME CRT, RR2
    ZURICH
    ON
    N0M2T0

    This document may be used as an official receipt

    Claim Type Service Description Billed Excluded Deductible Eligible % Payable Message
    Date Code
    Massage 14 Aug 2023 249432 - Massage Therapist - 95.00 0.00 0.00 95.00 100% 95.00
    Therapy Visit
    Massage 30 Aug 2023 249432 - Massage Therapist - 95.00 0.00 0.00 95.00 100% 95.00
    Therapy Visit
    Massage 25 Sep 2023 249432 - Massage Therapist - 95.00 0.00 0.00 95.00 100% 95.00
    Therapy Visit
    Massage 16 Oct 2023 249432 - Massage Therapist - 95.00 0.00 0.00 95.00 100% 95.00
    Therapy Visit
    Massage 06 Nov 2023 249432 - Massage Therapist - 95.00 0.00 0.00 95.00 100% 95.00
    Therapy Visit
    Totals 475.00 0.00 0.00 475.00 475.00

    Total Billed 475.00


    - FHCPS Pays 475.00
    Excluded for 0.00
    FHCPS

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