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  • BP0000130263 1

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    This document is an explanation of benefits from Orient Takaful Insurance Company for a claim submitted by Mervat Sami Abdol. It provides details of a cesarean delivery procedure performed at a provider not in the insurance company's network. The total claimed amount was 5500 Egyptian pounds, with 2572.65 pounds excluded up to the maximum maternity limit. The payable amount approved was 2927.35 Egyptian pounds.

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    BP0000130263-1

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    This document is an explanation of benefits from Orient Takaful Insurance Company for a claim submitted by Mervat Sami Abdol. It provides details of a cesarean delivery procedure performed at a provider not in the insurance company's network. The total claimed amount was 5500 Egyptian pounds, with 2572.65 pounds excluded up to the maximum maternity limit. The payable amount approved was 2927.35 Egyptian pounds.

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    © All Rights Reserved
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    3 views1 page

    BP0000130263 1

    Uploaded by

    abanoub.ebrahiem253
    This document is an explanation of benefits from Orient Takaful Insurance Company for a claim submitted by Mervat Sami Abdol. It provides details of a cesarean delivery procedure performed at a provider not in the insurance company's network. The total claimed amount was 5500 Egyptian pounds, with 2572.65 pounds excluded up to the maximum maternity limit. The payable amount approved was 2927.35 Egyptian pounds.

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

    Claims Evaluation Sheet - Explanation Of Benefits

    Payer: Orient Takaful Insurance Company Policy: MAGRABi - 23/100/8001/0002023

    Beneficiary Name: Mervat Sami Abdol Card #: D3DB756002AE912D


    Employee #: 4291 Category: B
    Product : MAGRABi B

    ASOAP
    ASOAP #: BP0000130263 Claim Date: 10-Oct-2023
    Invoice #: 001 Emergency: False
    Provider Name: Provider not in General Network Reception Date: 22-Oct-2023
    FOB: In-Patient FOC: Maternity
    Spec.Assess (ICD9) 669.71 Cesarean delivery, without mention of indication, delivered, with or without mention of antepartum condition

    Batch / Payment Order


    Batch ID: 753437 Claimed Amount in EGP: 5500.0
    PO ID: 845335 Non-payable Amount in EGP: 2572.65
    PO Date: 29-Oct-2023 Payable Amount in EGP: 2927.35

    Numbers are all in EGP


    Claimed Approved NonPayer
    Service and Items Ded. Co-Par Benef Share Payer Share Reason
    Amount Amount Share
    Accommodation Rate-Royal Suite (ACC- Not per agreed
    5500 2927.35 0 0 0 2927.35 2572.65
    1) tariff
    Total 5500 2927.35 0 0 0 2927.35 2572.65

    Services : Ceasrean section (Medical Team Fees )


    total Amount :5500 LE
    Amount Excluded :2572.65 LE ( Reason :Up to max maternity limit )
    CO-Insurance :0 LE
    Payable :2927.35 LE

    Page 1 of 1

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