Claim Date: 2024-06-12

MUM'S CARE HOSPITAL-WOODLANDS Claim Number: 08B1-10164-57071-6FC

Practice Number: ZM738355 Claim Status: Partially Accepted
Web User: ZM738355-03
NHIMA
Member Number: 34210045110127
Dependant Code: 00
Member Name: MS ESNART MWALE
Date of Birth: 1981-10-27

Date Code Description Diag. Qty Total Cost Scheme Pay Patient Pay
2024-06-12 ZCAP1701 INITIAL VISIT ( OPD REGISTRATION & CONSULTATION LEVEL TWO& J00 1.00 600.00 0.00 600.00
R - 6016: SCHEME RULES APPLIED
2024-06-12 10002 AMOXYCILLIN (TRIHYDRATE) (250MG - CAPSULE) J00 15.00 0.00 0.00 0.00
W - 3002: CLAIM UNDER REVIEW
2024-06-12 90006 PARACETAMOL (500MG - TABLET) J00 20.00 0.00 0.00 0.00
W - 3002: CLAIM UNDER REVIEW
2024-06-12 50007 COUGH MIXTURE(VARIES - LIQUID) J00 1.00 0.00 0.00 0.00
W - 3002: CLAIM UNDER REVIEW
600.00 0.00 600.00

Submitted via NHIMA Online Claim Capture