10374597 2023/04/01

MISS MARTHA MALI Ref: 38144055

3094 TUMBUYU CRESCENT
BUDIRIDO 2
HARARE

Claims Advice
Option Member Statement Period
Ruby 10374597 58 01/03/2023 To 31/03/2023

See the end section of the statement for a detailed explanation of statement contents and reasons

Claims
Provider: FIRST MUTUAL LIFE MEDICAL CLIN (2012085859 / 62493)
Treatment Date Claimed Accept Scheme Savings Member Pay To Refund Reasons
Amount Amount Amount Amount Liable Provider To You
Patient: MISS NYASHA B KUFA
02/03/2023 18,007.20 16,400.00 2,655.90 13,744.10 1,607.20 16,400.00 0.00 6
Provider: WALNUT PHARMACY (13034771 / 91523)
Treatment Date Claimed Accept Scheme Savings Member Pay To Refund Reasons
Amount Amount Amount Amount Liable Provider To You
Patient: MISS NYASHA B KUFA
02/03/2023 36,697.05 36,697.05 0.00 36,697.05 0.00 36,697.05 0.00
02/03/2023 6,850.00 6,850.00 0.00 6,850.00 0.00 6,850.00 0.00
02/03/2023 10,100.76 10,100.76 0.00 10,100.76 0.00 10,100.76 0.00
02/03/2023 33,189.09 33,189.09 0.00 33,189.09 0.00 33,189.09 0.00
Sub Totals 86,836.90 86,836.90 0.00 86,836.90 0.00 86,836.90 0.00
Statement Totals 104,844.10 103,236.90 2,655.90 100,581.00 1,607.20 103,236.90 0.00

Reasons explained
Reason Description
6 Amount claimed exceeds tariff amount

Statement columns explained

Column Explanation
Treatment Date Indicates the date of treatment
Claimed Amount The amount submitted
Accepted Amount The amount the system accepted
Member Liable Possible Member liability (excluding electronic rejected pharmacy claims)
Scheme Amount The amount paid for by the scheme
Savings Amount The amount paid from savings
Pay To Provider Amount paid to the provider by the scheme
Refund to You Amount refunded to you by the scheme
Reasons A list of reason codes explaining the current balance of the claim

First Mutual Health

Head Office: First Mutual Park 100 Borrowdale Road Borrowdale Harare
P. O. Box 1083 Harare, Zimbabwe
Telephone: +263 242 886018-38 Fax: +263 242 886068-9
Email: info@fmlmedical.co.zw Web: www.fmlmedical.co.zw
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