11/04/2019

Explanation of Benefits
Risk Carrier : LIBANO SUISSE Policy Holder Name : EMC- San Masr
Member : 50007228 50015477 Staff # : 004855-01 Provider : Al Mokhtabr Laboratories - Roxy 1
Claim Number : 17959567
MCN : 23099488 Batch # : 0
Principal Name : MAHMOUD M IBRAHIM
Name : MAHMOUD IBRAHIM
Date Of Birth : 1984

Transaction Date : 11/04/2019 Invoice Number : Physician : Nozha International Hospital Default Doctor

Diagnosis : Other and unspecified abdominal pain Approved by

Detailed Bill Med File : Cons. Fees : 0.00 EGP SSNBR : 30306300

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

LABORATORY 1- SGOT (AST) 25.00 1 EGP 25.00 1 25.00 0.00

2- SGPT (ALT) 25.00 1 EGP 25.00 1 25.00 0.00

3- Complete Blood Picture (CBC) 55.00 1 EGP 55.00 1 55.00 0.00

4- ESR 25.00 1 EGP 25.00 1 25.00 0.00

5- CRP (Quantitative) 50.00 1 EGP 50.00 1 50.00 0.00

Summary Patient Share

Total Claimed 180.00 EGP Co-Insurance 0.00 EGP
Total Approved 180.00 EGP Exceeding Limitation 0.00 EGP
Discount 0.00 EGP Uncovered Items 0.00 EGP

Net Amount 180.00 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 2
 Explanation of Benefits
Risk Carrier : LIBANO SUISSE Policy Holder Name : EMC- San Masr
Member : 50007228 50015477 Staff # : 004855-01 Provider : Al Mokhtabr Laboratories - Roxy 1
Claim Number : 17959567
MCN : 23099488 Batch # : 0
Principal Name : MAHMOUD M IBRAHIM
Name : MAHMOUD IBRAHIM
Date Of Birth : 1984

Transaction Date : 11/04/2019 Invoice Number : Physician : Nozha International Hospital Default Doctor
Service Item Unit Price Type Qty Claimed Curr Total Claimed Qty Appr. Total Appr. Disc.

Summary Patient Share

Total Claimed 180.00 EGP Co-Insurance 0.00 EGP
Total Approved 180.00 EGP Exceeding Limitation 0.00 EGP
Discount 0.00 EGP Uncovered Items 0.00 EGP

Net Amount 180.00 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 2 of 2