Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.

File Ref. Code Date code

E7311537 001110889043201 Nouf Saud Ahmad Alnowirah 31297 2217 K02 04-04-2023 CCN08

E7311537 001110889043201 Nouf Saud Ahmad Alnowirah 31297 2217 K02 04-04-2023 CCN08

E7311537 001110889043201 Nouf Saud Ahmad Alnowirah 31297 2152 K02 02-04-2023 GCN15
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject Reasons
Disc Dedcut Price Limit Amount VAT
COMPOSITE FILLING 1 1 0 0 80 12 Exceeding the Approved Amount -
SURFACE
COMPOSITE FILLING 1 1 0 0 80 12 Exceeding the Approved Amount -
SURFACE
SCALING AND POLISHING 1 0 0 120 18 Exceeding the Approved Amount -
LNCLUDING PROPHY MATE
 Reasons justification approval number

Exceeding the Approved Amount - THE REQUSITED 23476397

SURVEICE WAS
Exceeding the Approved Amount - THEAPROVED
REQUSITED 23476397
SURVEICE WAS
Exceeding the Approved Amount - THEAPROVED
REQUSITED 23437072
SURVEICE WAS
APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7041968 001027483765231 Reem Faleh Mohammed 23706 455 K02 21-01-2023 PCN12
Alajmi
E7041968 001027483765231 Reem Faleh Mohammed 23706 617 K02 28-01-2023 CCN11
Alajmi
E7041968 001027483765231 Reem Faleh Mohammed 23706 701 K02 30-01-2023 CCN11
Alajmi
E7041968 001027483765231 Reem Faleh Mohammed 23706 617 K02 28-01-2023 CCN10
Alajmi
E7041968 001027483765231 Reem Faleh Mohammed 23706 701 K02 30-01-2023 CCN08
Alajmi
E7041968 001027483765231 Reem Faleh Mohammed 23706 455 K02 21-01-2023 CCN11
Alajmi
E7041968 001027483765231 Reem Faleh Mohammed 23706 455 K02 21-01-2023 DCN01
Alajmi
Evaluator Notes
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject Reasons
Disc Dedcut Price Limit Amount VAT
COMPOSITE FILLING 3 1 0 0 160 24 Exceeding the Approved Amount -
SURFACE
COMPOSITE BUILDUP WITH 1 0 0 160 24 Exceeding the Approved Amount -
PINS
COMPOSITE BUILDUP WITH 1 0 0 160 24 Exceeding the Approved Amount -
PINS
COMPOSITE FILLING 3 1 0 0 140 21 Exceeding the Approved Amount -
SURFACE
COMPOSITE FILLING 1 1 0 0 80 12 Exceeding the Approved Amount -
SURFACE
COMPOSITE BUILDUP WITH 1 0 0 160 24 Exceeding the Approved Amount -
PINS
EXAMINATIONAND 1 0 0 40 6 Exceeding the Approved Amount -
DIAGNOSIS STANDARD
 Reasons justification approval number

Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS APROVED 21845300

Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS APROVED 22010131

Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS APROVED 22070632

Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS APROVED 22010131

Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS APROVED 22070632

Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS APROVED 21845300

Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS APROVED 21845300
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7041982 001099737924001 Ghadah Mansour Mohammed 30670 403 K02 17-01-2023 ECN05
Alburaidi
E7041982 001099737924001 Ghadah Mansour Mohammed 30670 260 K02 12-01-2023 DCN01
Alburaidi
E7041982 001099737924001 Ghadah Mansour Mohammed 30670 260 K02 12-01-2023 DCN05
Alburaidi
E7041982 001099737924001 Ghadah Mansour Mohammed 30670 260 K02 12-01-2023 GCN15
Alburaidi
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject Reasons
Disc Dedcut Price Limit Amount VAT
RE TREATMENT ONE 1 0 0 280 42 Exceeding the Approved Amount -
CANAL
EXAMINATIONAND 1 0 0 40 6 Exceeding the Approved Amount -
DIAGNOSIS STANDARD
OPG XRAY 1 0 0 80 12 Exceeding the Approved Amount -

SCALING AND POLISHING 1 0 0 120 18 Exceeding the Approved Amount -

LNCLUDING PROPHY MATE
 Reasons justification approval number

Exceeding the Approved Amount - THE REQUSITED 21779123

SURVEICE WAS
Exceeding the Approved Amount - THEAPROVED
REQUSITED Exceeding the Approved
SURVEICE WAS Amount -
Exceeding the Approved Amount - THEAPROVED
REQUSITED Exceeding the Approved
SURVEICE WAS Amount -
Exceeding the Approved Amount - THEAPROVED
REQUSITED Exceeding the Approved
SURVEICE WAS Amount -
APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7042007 002156852499001 Reham Altayeb Abdullah 29424 314 K02 14-01-2023 DCN03
Siddiq
E7042007 002156852499001 Reham Altayeb Abdullah 29424 314 K02 14-01-2023 CCN09
Siddiq
E7042007 002156852499001 Reham Altayeb Abdullah 29424 314 K02 14-01-2023 CCN08
Siddiq
E7042007 002156852499001 Reham Altayeb Abdullah 29424 314 K02 14-01-2023 CCN09
Siddiq
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject Reasons
Disc Dedcut Price Limit Amount VAT
PA INTRAORAL XRAY 1 0 15 2.25 This Provider is Blocked -

COMPOSITE FILLING 2 1 0 125 18.75 This Provider is Blocked -

SURFACE
COMPOSITE FILLING 1 1 0 80 12 This Provider is Blocked -
SURFACE
COMPOSITE FILLING 2 1 0 120 18 This Provider is Blocked -
SURFACE
 Reasons

This Provider is Blocked -

This Provider is Blocked -

This Provider is Blocked -

This Provider is Blocked -

Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7042012 002193050123001 Hani Mohammed Mohammed 30717 542 K02 24-01-2023 DCN03
Alshyshy
E7042012 002193050123001 Hani Mohammed Mohammed 30717 376 K02 16-01-2023 DCN01
Alshyshy
E7042012 002193050123001 Hani Mohammed Mohammed 30717 564 K02 22-01-2023 DCN03
Alshyshy
E7042012 002193050123001 Hani Mohammed Mohammed 30717 564 K02 22-01-2023 CCN10
Alshyshy
E7042012 002193050123001 Hani Mohammed Mohammed 30717 564 K02 22-01-2023 CCN10
Alshyshy
E7042012 002193050123001 Hani Mohammed Mohammed 30717 564 K02 22-01-2023 CCN09
Alshyshy
E7042012 002193050123001 Hani Mohammed Mohammed 30717 564 K02 22-01-2023 DCN03
Alshyshy
E7042012 002193050123001 Hani Mohammed Mohammed 30717 376 K02 16-01-2023 DCN05
Alshyshy
E7042012 002193050123001 Hani Mohammed Mohammed 30717 376 K02 16-01-2023 GCN15
Alshyshy
E7042012 002193050123001 Hani Mohammed Mohammed 30717 542 K02 24-01-2023 CCN09
Alshyshy
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject Reasons
Disc Dedcut Price Limit Amount VAT
PA INTRAORAL XRAY 1 0 0 12 1.8 Exceeding the Approved Amount -

EXAMINATIONAND 1 0 0 40 6 Exceeding the Approved Amount -

DIAGNOSIS STANDARD
PA INTRAORAL XRAY 1 0 0 12 1.8 Exceeding the Approved Amount -

COMPOSITE FILLING 3 1 0 0 168 25.2 Exceeding the Approved Amount -

SURFACE
COMPOSITE FILLING 3 1 0 0 140 21 Exceeding the Approved Amount -
SURFACE
COMPOSITE FILLING 2 1 0 0 120 18 Exceeding the Approved Amount -
SURFACE
PA INTRAORAL XRAY 1 0 0 15 2.25 Exceeding the Approved Amount -

OPG XRAY 1 0 0 80 12 Exceeding the Approved Amount -

SCALING AND POLISHING 1 0 0 120 18 Exceeding the Approved Amount -

LNCLUDING PROPHY MATE
COMPOSITE FILLING 2 1 0 0 120 18 Exceeding the Approved Amount -
SURFACE
 Reasons justification approval number

Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS 21928886

APROVED
Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS 21747309
APROVED
Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS 21874199
APROVED
Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS 21874199
APROVED
Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS 21874199
APROVED
Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS 21874199
APROVED
Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS 21874199 -
APROVED
Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS 21747309
APROVED
Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS 21747309
APROVED
Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS 21928886
APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7042016 002403341304001 Melchor Jr Uao Felipe 21780 16 K02 01-01-2023 DCN05
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject Reasons
Disc Dedcut Price Limit Amount VAT
OPG XRAY 1 5 0 0 0 0.75 Exceeding the Approved Amount -
 Reasons justification approval number

Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS APROVED 21393214
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7042021 001081700245001 Mohammad Moataz S Faresi 28554 127 K02 05-01-2023 DCN03
E7042021 001081700245001 Mohammad Moataz S Faresi 28554 127 K02 05-01-2023 DCN03
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval namber
Disc Dedcut Price Limit Amount VAT
PA INTRAORAL XRAY 1 3 0 0 0 0.45 21490466
PA INTRAORAL XRAY 1 3 0 0 0 0.45 21490466
approval namber Reasons justification

21490466 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS

21490466 Exceeding the Approved Amount -
APROVED
THE REQUSITED SURVEICE WAS
APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7108369 001076552890001 Yazeed Abdullah Saeed 30897 896 Z01.2 08-02-2023 DCN05
Alahmari
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT
OPG XRAY 1 0 100 15 22259428
 approval number Reasons justification

22259428 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS

APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7121647 002016442390221 Leen Hatim Jamal Alhindi 30995 1370 K02 27-02-2023 CCN10
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT
COMPOSITE FILLING 3 1 0 0 140 21 22717346
SURFACE
approval number Reasons justification

22717346 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS

APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7269865 001094522487001 Hind Nasser G Alotaibi 28921 2058 K05.0 29-03-2023 GCN15
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT
SCALING AND POLISHING 1 0 120 18 23362409
LNCLUDING PROPHY MATE
approval number Reasons justification

23362409 Exceeding the Approved Amount - THE REQUSITED SURVEICE

WAS APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7269879 001087960785001 Fatimah Saleh Abdulmosen 31154 1688 K02 12-03-2023 CCN10
Alauwaid
E7269879 001087960785001 Fatimah Saleh Abdulmosen 31154 1580 K02 07-03-2023 GCN15
Alauwaid
E7269879 001087960785001 Fatimah Saleh Abdulmosen 31154 1580 K02 07-03-2023 DCN03
Alauwaid
E7269879 001087960785001 Fatimah Saleh Abdulmosen 31154 1580 K02 07-03-2023 DCN03
Alauwaid
E7269879 001087960785001 Fatimah Saleh Abdulmosen 31154 1580 K02 07-03-2023 DCN05
Alauwaid
E7269879 001087960785001 Fatimah Saleh Abdulmosen 31154 1688 K02 12-03-2023 CCN10
Alauwaid
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT
COMPOSITE FILLING 3 1 0 0 140 21 23022870
SURFACE
SCALING AND POLISHING 1 0 0 120 18 Exceeding the Approved Amount -
LNCLUDING PROPHY MATE
PA INTRAORAL XRAY 1 0 0 12 1.8 Exceeding the Approved Amount -

PA INTRAORAL XRAY 1 0 0 12 1.8 Exceeding the Approved Amount -

OPG XRAY 1 0 0 80 12 Exceeding the Approved Amount -

COMPOSITE FILLING 3 1 0 0 140 21 23022870

SURFACE
 approval number
23022870
Exceeding the Approved Amount -
Exceeding the Approved Amount -
Exceeding the Approved Amount -
Exceeding the Approved Amount -
23022870
Reasons justification
Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7269871 001091829968001 Rola Saud Hamoud Alharbi 28304 1747 K02 13-03-2023 DCN03
E7269871 001091829968001 Rola Saud Hamoud Alharbi 28304 1570 K02 07-03-2023 GCN15

E7269871 001091829968001 Rola Saud Hamoud Alharbi 28304 1747 K02 13-03-2023 CCN10

E7269871 001091829968001 Rola Saud Hamoud Alharbi 28304 1747 K02 13-03-2023 CCN10

E7269871 001091829968001 Rola Saud Hamoud Alharbi 28304 1747 K02 13-03-2023 DCN03

Evaluator Notes
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT
PA INTRAORAL XRAY 1 0 0 13 1.95 23053137
SCALING AND POLISHING 1 0 0 120 18 22922722
LNCLUDING PROPHY MATE
COMPOSITE FILLING 3 1 0 0 140 21 23053137
SURFACE
COMPOSITE FILLING 3 1 0 0 140 21 23053137
SURFACE
PA INTRAORAL XRAY 1 0 0 12 1.8 23053137
 approval number Reasons justification

23053137 Exceeding the Approved Amount - THE REQUSITED

22922722 Exceeding the Approved Amount -
SURVEICE WAS
THE REQUSITED
APROVED
SURVEICE WAS
23053137 Exceeding the Approved Amount - THEAPROVED
REQUSITED
SURVEICE WAS
23053137 Exceeding the Approved Amount - THEAPROVED
REQUSITED
SURVEICE WAS
23053137 Exceeding the Approved Amount - THEAPROVED
REQUSITED
SURVEICE WAS
APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7269880 001105184590001 Wafa Aldirdah Bin Hindi 31203 1803 K02 15-03-2023 CCN10
Alrushud
E7269880 001105184590001 Wafa Aldirdah Bin Hindi 31203 1803 K02 15-03-2023 CCN10
Alrushud
E7269880 001105184590001 Wafa Aldirdah Bin Hindi 31203 1803 K02 15-03-2023 CCN09
Alrushud
E7269880 001105184590001 Wafa Aldirdah Bin Hindi 31203 1727 K02 13-03-2023 GCN15
Alrushud
E7269880 001105184590001 Wafa Aldirdah Bin Hindi 31203 1727 K02 13-03-2023 DCN05
Alrushud
E7269880 001105184590001 Wafa Aldirdah Bin Hindi 31203 1727 K02 13-03-2023 DCN01
Alrushud
E7269880 001105184590001 Wafa Aldirdah Bin Hindi 31203 1803 K02 15-03-2023 DCN03
Alrushud
E7269880 001105184590001 Wafa Aldirdah Bin Hindi 31203 1803 K02 15-03-2023 DCN03
Alrushud
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT
COMPOSITE FILLING 3 1 0 0 140 21 23098305
SURFACE
COMPOSITE FILLING 3 1 0 0 140 21 23098305
SURFACE
COMPOSITE FILLING 2 1 0 0 120 18 23098305
SURFACE
SCALING AND POLISHING 1 0 0 120 18 23044596
LNCLUDING PROPHY MATE
OPG XRAY 1 0 0 80 12 23044596

EXAMINATIONAND 1 0 0 40 6 23044596
DIAGNOSIS STANDARD
PA INTRAORAL XRAY 1 0 0 15 2.25 23098305

PA INTRAORAL XRAY 1 0 0 15 2.25 23098305

 approval number Reasons justification

23098305 Exceeding the Approved Amount - THE REQUSITED SURVEICE

WAS APROVED
23098305 Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
23098305 Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
23044596 Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
23044596 Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
23044596 Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
23098305 Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
23098305 Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7269881 002376304008001 Ibrahim Ahmed Mohamed 31221 1812 K02 15-03-2023 DCN03
Hussein
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT
PA INTRAORAL XRAY 3 30 0 0 0 4.5 23096869-
approval number Reasons justification

23096869- Exceeding the Approved Amount - THE REQUSITED

SURVEICE WAS
APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7269883 002000002301001 Sabrin Hashim Abdela 31267 1999 K02 26-03-2023 DCN03
E7269883 002000002301001 Sabrin Hashim Abdela 31267 2021 K02 27-03-2023 CCN09

E7269883 002000002301001 Sabrin Hashim Abdela 31267 2021 K02 27-03-2023 CCN09

E7269883 002000002301001 Sabrin Hashim Abdela 31267 1999 K02 26-03-2023 CCN09

E7269883 002000002301001 Sabrin Hashim Abdela 31267 2021 K02 27-03-2023 CCN08

E7269883 002000002301001 Sabrin Hashim Abdela 31267 1999 K02 26-03-2023 CCN08

E7269883 002000002301001 Sabrin Hashim Abdela 31267 2021 K02 27-03-2023 DCN03
E7269883 002000002301001 Sabrin Hashim Abdela 31267 2021 K02 27-03-2023 CCN10

E7269883 002000002301001 Sabrin Hashim Abdela 31267 1999 K02 26-03-2023 CCN10

E7269883 002000002301001 Sabrin Hashim Abdela 31267 1999 K02 26-03-2023 DCN03
E7269883 002000002301001 Sabrin Hashim Abdela 31267 1999 K02 26-03-2023 DCN03
E7269883 002000002301001 Sabrin Hashim Abdela 31267 2021 K02 27-03-2023 DCN03
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT
PA INTRAORAL XRAY 1 0 0 14.25 2.14 23316065
COMPOSITE FILLING 2 1 0 0 142.5 21.38 23332963
SURFACE
COMPOSITE FILLING 2 1 0 0 142.5 21.38 23332963
SURFACE
COMPOSITE FILLING 2 1 0 0 142.5 21.38 23316065
SURFACE
COMPOSITE FILLING 1 1 0 0 95 14.25 23332963
SURFACE
COMPOSITE FILLING 1 1 0 0 95 14.25 23316065
SURFACE
PA INTRAORAL XRAY 1 0 0 14.25 2.14 23332963
COMPOSITE FILLING 3 1 0 0 166.25 24.94 23332963
SURFACE
COMPOSITE FILLING 3 1 0 0 166.25 24.94 23316065
SURFACE
PA INTRAORAL XRAY 1 0 0 14.25 2.14 23316065
PA INTRAORAL XRAY 1 0 0 14.25 2.14 23316065
PA INTRAORAL XRAY 1 0 0 14.25 2.14 23332963
 approval number Reasons justification

23316065 Exceeding the Approved Amount - THE REQUSITED SURVEICE

23332963 Exceeding the Approved Amount -
WAS APROVED
THE REQUSITED SURVEICE
WAS APROVED
23332963 Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
23316065 Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
23332963 Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
23316065 Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
23332963 Exceeding the Approved Amount - THE REQUSITED SURVEICE
23332963 Exceeding the Approved Amount -
WAS APROVED
THE REQUSITED SURVEICE
WAS APROVED
23316065 Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
23316065 Exceeding the Approved Amount - THE REQUSITED SURVEICE
23316065 Exceeding the Approved Amount -
WAS APROVED
THE REQUSITED SURVEICE
23332963 Exceeding the Approved Amount -
WAS APROVED
THE REQUSITED SURVEICE
WAS APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7269885 001035079183211 Ikhlas Fahad Muslih Alqahtani 31282 1985 K02 26-03-2023 CCN10
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT
COMPOSITE FILLING 3 1 0 0 143 21.45 23299231
SURFACE
approval number Reasons justification

23299231 Exceeding the Approved Amount - THE REQUSITED

SURVEICE WAS
APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7311533 001081700245001 Mohammad Moataz S Faresi 28554 2435 K02 15-04-2023 GCN15
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT
SCALING AND POLISHING 1 0 0 30 18 23665279
LNCLUDING PROPHY MATE
 approval number Reasons justification

23665279 Exceeding the Approved Amount - THE REQUSITED

SURVEICE WAS APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7311538 001080742230001 Ahmad Salem Mohammed 31307 2164 K02 03-04-2023 CCN09
Alharby
E7311538 001080742230001 Ahmad Salem Mohammed 31307 2164 K02 03-04-2023 CCN09
Alharby
E7311538 001080742230001 Ahmad Salem Mohammed 31307 2262 K02 07-04-2023 CCN09
Alharby
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject s
Disc Dedcut Price Limit Amount VAT
COMPOSITE FILLING 2 1 0 0 120 18 23444422
SURFACE
COMPOSITE FILLING 2 1 0 0 120 18 23444422
SURFACE
COMPOSITE FILLING 2 1 0 0 60 18 23527158
SURFACE
 Reasons justification

Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS

APROVED
Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
APROVED
Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7316932 001067704476001 Noura Ali Mutlaq Alqhtani 29946 2297 K02 09-04-2023 ECN04
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT
RCT THREE CANALS 1 0 0 298 97.95 23558555
 approval number Reasons justification

23558555 Exceeding the Approved Amount - THE REQUSITED

SURVEICE WAS APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7311543 001095323232001 Nujud Abdullah Salem 31360 2208 K02 04-04-2023 DCN05
Almuhayzi
E7311543 001095323232001 Nujud Abdullah Salem 31360 2209 K02 03-04-2023 DCN01
Almuhayzi
E7311543 001095323232001 Nujud Abdullah Salem 31360 2209 K02 03-04-2023 GCN15
Almuhayzi
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT
OPG XRAY 1 0 0 80 12 23475146

EXAMINATIONAND 1 0 0 40 6 23458163
DIAGNOSIS STANDARD
SCALING AND POLISHING 1 0 0 80 18 23458163
LNCLUDING PROPHY MATE
 approval number Reasons justification

23475146 Exceeding the Approved Amount - THE REQUSITED SURVEICE

WAS APROVED
23458163 Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
23458163 Exceeding the Approved Amount - THE REQUSITED SURVEICE
WAS APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7311546 001085802112001 Faisal Thakkar Naif Albaqami 31431 2505 K02 12-04-2023 CCN10

E7311546 001085802112001 Faisal Thakkar Naif Albaqami 31431 2503 K02 19-04-2023 CCN10

E7311546 001085802112001 Faisal Thakkar Naif Albaqami 31431 2505 K02 12-04-2023 CCN10

E7311546 001085802112001 Faisal Thakkar Naif Albaqami 31431 2505 K02 12-04-2023 DCN03
E7311546 001085802112001 Faisal Thakkar Naif Albaqami 31431 2505 K02 12-04-2023 DCN03
E7311546 001085802112001 Faisal Thakkar Naif Albaqami 31431 2505 K02 12-04-2023 CCN10

E7311546 001085802112001 Faisal Thakkar Naif Albaqami 31431 2503 K02 19-04-2023 CCN10

E7311546 001085802112001 Faisal Thakkar Naif Albaqami 31431 2505 K02 12-04-2023 DCN05
E7311546 001085802112001 Faisal Thakkar Naif Albaqami 31431 2505 K02 12-04-2023 DCN01

E7311546 001085802112001 Faisal Thakkar Naif Albaqami 31431 2503 K02 19-04-2023 CCN10
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT
COMPOSITE FILLING 3 1 0 0 175 26.25 23639334
SURFACE
COMPOSITE FILLING 3 1 0 0 145 21.75 23720282
SURFACE
COMPOSITE FILLING 3 1 0 0 140 21 23639334
SURFACE
PA INTRAORAL XRAY 1 0 0 15 2.25 23639334
PA INTRAORAL XRAY 1 0 0 15 2.25 23639334
COMPOSITE FILLING 3 1 0 0 140 21 23639334
SURFACE
COMPOSITE FILLING 3 1 0 0 140 21 23720282
SURFACE
OPG XRAY 1 0 0 80 12 23639334
EXAMINATIONAND 1 0 0 40 6 23639334
DIAGNOSIS STANDARD
COMPOSITE FILLING 3 1 0 0 140 21 23720282
SURFACE
 approval number Reasons justification

23639334 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS

APROVED
23720282 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
APROVED
23639334 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
APROVED
23639334 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
23639334 Exceeding the Approved Amount -
APROVED
THE REQUSITED SURVEICE WAS
23639334 Exceeding the Approved Amount -
APROVED
THE REQUSITED SURVEICE WAS
APROVED
23720282 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
APROVED
23639334 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
23639334 Exceeding the Approved Amount -
APROVED
THE REQUSITED SURVEICE WAS
APROVED
23720282 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7451876 002537879286002 Shiref Mohamed Mohamed 31788 3438 K02 31-05-2023 ECN03
Ahmed
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT
RCT TWO CANALS 1 0 0 300 65.25 24440449
 approval number Reasons justification

24440449 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS

APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7451868 002250533961001 Mohammad Fadel Abdelqader 31720 3247 K02 24-05-2023 CCN10
Khalil
E7451868 002250533961001 Mohammad Fadel Abdelqader 31720 3247 K02 24-05-2023 CCN08
Khalil
E7451868 002250533961001 Mohammad Fadel Abdelqader 31720 3446 K02 31-05-2023 CCN08
Khalil
E7451868 002250533961001 Mohammad Fadel Abdelqader 31720 3247 K02 24-05-2023 DCN01
Khalil
E7451868 002250533961001 Mohammad Fadel Abdelqader 31720 3247 K02 24-05-2023 DCN03
Khalil
E7451868 002250533961001 Mohammad Fadel Abdelqader 31720 3247 K02 24-05-2023 DCN03
Khalil
E7451868 002250533961001 Mohammad Fadel Abdelqader 31720 3247 K02 24-05-2023 DCN05
Khalil
E7451868 002250533961001 Mohammad Fadel Abdelqader 31720 3247 K02 24-05-2023 CCN10
Khalil
E7451868 002250533961001 Mohammad Fadel Abdelqader 31720 3446 K02 31-05-2023 CCN09
Khalil
E7451868 002250533961001 Mohammad Fadel Abdelqader 31720 3446 K02 31-05-2023 DCN03
Khalil
Evaluator Notes
Total
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT
COMPOSITE FILLING 3 1 0 0 166 24.9 24331674
SURFACE
COMPOSITE FILLING 1 1 0 0 80 12 24331674
SURFACE
COMPOSITE FILLING 1 1 0 0 68 12 24442793
SURFACE
EXAMINATIONAND 1 0 0 40 6 24331674
DIAGNOSIS STANDARD
PA INTRAORAL XRAY 1 0 0 12 1.8 24331674

PA INTRAORAL XRAY 1 0 0 12 1.8 24331674

OPG XRAY 1 0 0 80 12 24331674

COMPOSITE FILLING 3 1 0 0 140 21 24331674

SURFACE
COMPOSITE FILLING 2 1 0 0 120 18 24442793
SURFACE
PA INTRAORAL XRAY 1 0 0 12 1.8 24442793

0 0 730 111.3
 approval number Reasons justification

24331674 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS

APROVED
24331674 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
APROVED
24442793 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
APROVED
24331674 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
APROVED
24331674 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
APROVED
24331674 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
APROVED
24331674 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
APROVED
24331674 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
APROVED
24442793 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
APROVED
24442793 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code
E7451888 001081035360001 Ibrahim Saad S Alanazi 31718 3278 K02 25-05-2023 CCN10

E7451888 001081035360001 Ibrahim Saad S Alanazi 31718 3357 K02 28-05-2023 CCN10

E7451888 001081035360001 Ibrahim Saad S Alanazi 31718 3357 K02 28-05-2023 CCN10

Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code

E7463293 002133695433241 Karam Ghassan Faez Altabbae 31773 3401 K02 29-05-2023 CCN08

Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code

E7451872 001034442747001 Ahmed Mohammed Mofareh 31776 3418 K02 30-05-2023 SCN02
Alotaibi
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT
COMPOSITE FILLING 3 1 0 0 140 21 24347527
SURFACE
COMPOSITE FILLING 3 1 0 0 140 21 24396303
SURFACE
COMPOSITE FILLING 3 1 0 0 140 21 24396303
SURFACE

Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT

COMPOSITE FILLING 1 1 32 0 0 4.8 24415917-

SURFACE

Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT

SURGICAL EXTRACTION 1 0 160 24 24426604

NON WISDOM
 approval number Reasons justification

24347527 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS

APROVED
24396303 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
APROVED
24396303 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS
APROVED

approval number Reasons justification

24415917- Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS

APROVED
approval number Reasons justification

24426604 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS

APROVED
Claim No. Patient No. Patient Name Patient Provider ICD10 Service Rec.
File Ref. Code Date code

E7553720 002379234244001 Rabi Mousa Khader Torkman 31685 4246 K02 22-06-2023 ECN03
 Service QTY Diff In Diff In Exceed Exceed Rejected Reject approval number
Disc Dedcut Price Limit Amount VAT

RCT TWO CANALS 1 0 0 425 63.75 24736943

approval number Reasons justification

24736943 Exceeding the Approved Amount - THE REQUSITED SURVEICE WAS

APROVED