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  • Explanation of Benefits

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    AmiraNagy
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    Amira Elsayed Nagy received an explanation of benefits from her insurance provider, AXA Gulf Guarantor, for various medical tests performed at Tecnoscan Radiology center. The document details the services received, including an ultrasound of the thyroid, abdomen, and heart, with a total claimed amount of 420 EGP. After applying a 147 EGP discount, the net approved amount was 273 EGP, of which the patient was not responsible for paying any amount.

    Original Description:

    ننن

    Original Title

    50156636 - Rad

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    Amira Elsayed Nagy received an explanation of benefits from her insurance provider, AXA Gulf Guarantor, for various medical tests performed at Tecnoscan Radiology center. The document details the services received, including an ultrasound of the thyroid, abdomen, and heart, with a total claimed amount of 420 EGP. After applying a 147 EGP discount, the net approved amount was 273 EGP, of which the patient was not responsible for paying any amount.

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

    Explanation of Benefits

    Uploaded by

    AmiraNagy
    Amira Elsayed Nagy received an explanation of benefits from her insurance provider, AXA Gulf Guarantor, for various medical tests performed at Tecnoscan Radiology center. The document details the services received, including an ultrasound of the thyroid, abdomen, and heart, with a total claimed amount of 420 EGP. After applying a 147 EGP discount, the net approved amount was 273 EGP, of which the patient was not responsible for paying any amount.

    Copyright:

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

    16/11/2014

    Explanation of Benefits
    Risk Carrier : AXA Gulf Guarantor
    Member
    : 50000315
    50156636

    Staff #

    MCN

    : 6080769

    Batch # : 0

    Name

    : AMIRA ELSAYED NAGY

    Policy Holder Name


    Provider
    Claim Number
    Principal Name

    :15541

    : AXA GULF
    : Tecnoscan (Osama Khalil Radiology center)-Morad St.
    :
    : AMIRA S ELSAYED NAGY

    Date Of Birth : 1991


    Transaction Date : 16/11/2014

    Invoice Number :

    Physician :

    Approved by

    Disorder of thyroid, unspecified

    Diagnosis :

    Med File :

    Detailed Bill
    Service
    ULTRASONOGRAPHY

    Default Doctor

    Cons. Fees :

    Item

    Unit Price

    0.00 EGP

    Type Qty Claimed Curr

    Total Claimed

    SSNBR :

    12542775

    Qty Appr.

    Total Appr.

    Disc.

    1-

    120.00

    1 EGP

    120.00

    120.00

    42.00

    2-

    100.00

    1 EGP

    100.00

    100.00

    35.00

    3-

    200.00

    1 EGP

    200.00

    200.00

    70.00

    Summary
    Total Claimed

    420.00

    EGP

    Patient Share
    Co-Insurance

    0.00

    EGP

    Total Approved

    420.00

    EGP

    Exceeding Limitation

    0.00

    EGP

    Discount

    147.00

    EGP

    Uncovered Items

    0.00

    EGP

    Net Amount

    273.00

    EGP

    Total Patient Share

    0.00

    EGP

    The claims will be subject to review and audit based on the Tariff, Discounts and Medical Necessity (Usual, Reasonable and Customary), on case by case basis. Thank You.

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