06/11/2017

Explanation of Benefits
Risk Carrier : GIGLT Policy Holder Name : Nine Contractors
Member : 50003510 50693302 Staff # : 36 Provider : El Nahar for Physiotherapy Center - Shoubra
Claim Number :
MCN : 15801807 Batch # : 0
Principal Name : MOHAMED S OSMAN
Name : MOHAMED OSMAN
Date Of Birth : 1985

Transaction Date : 06/11/2017 Invoice Number : Physician : Default Doctor

Diagnosis : Cervical disc disorder, unspecified Approved by

Detailed Bill Med File : Cons. Fees : 0.00 EGP SSNBR : 22731659

Service Item Unit Price Type Qty Claimed Curr Total Claimed Qty Appr. Total Appr. Disc.

Physiotherapy & 1- ‫ﺟﻠﺴﺔ ﻋﻼﺝ ﻃﺒﻴﻌﻲ ﺍﻟﺸﺎﻣﻠﺔ ﻟﻠﻌﻀﻮ ﺍﻟﻮﺍﺣﺪ‬ 25.00 6 EGP 150.00 6 150.00 0.00
rehabilitation

Summary Patient Share

Total Claimed 150.00 EGP Co-Insurance 0.00 EGP
Total Approved 150.00 EGP Exceeding Limitation 0.00 EGP
Discount 0.00 EGP Uncovered Items 0.00 EGP

Net Amount 150.00 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