14/04/2019

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

Transaction Date : 14/04/2019 Invoice Number : Physician : Default Doctor

Diagnosis : Arthritis, unspecified, site unspecified Approved by

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

2- ‫ﺃﺷﻌﻪ ﻋﺎﺩﻳﻪ ﻟﻠﺮﻛﺒﻪ‬ 250.00 1 EGP 250.00 1 250.00 62.50

Summary Patient Share

Total Claimed 500.00 EGP Co-Insurance 0.00 EGP
Total Approved 500.00 EGP Exceeding Limitation 0.00 EGP
Discount 125.00 EGP Uncovered Items 0.00 EGP

Net Amount 375.00 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. Page 1 of 1