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Explanation of Benefits
Explanation of Benefits
Explanation of Benefits
Risk Carrier : LIBANO SUISSE Policy Holder Name : EMC- San Masr
Member : 50007228 50015477 Staff # : 004855-01 Provider : Alfa Scan - Helioplis
Claim Number :
MCN : 23122924 Batch # : 0
Principal Name : MAHMOUD M IBRAHIM
Name : MAHMOUD IBRAHIM
Date Of Birth : 1984
Detailed Bill Med File : Cons. Fees : 0.00 EGP SSNBR : 30330256
Service Item Unit Price Type Qty Claimed Curr Total Claimed Qty Appr. Total Appr. Disc.
RADIOLOGY TESTS 1- ﺃﺷﻌﻪ ﻋﺎﺩﻳﻪ ﻟﻠﻜﺘﻒ ﻭﺿﻌﻴﻦ 250.00 1 EGP 250.00 1 250.00 62.50
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. Page 1 of 1