| Benefit | Sub Category | Patient Name | Submitted | Paid | Status | Service Date | Submitted Date |
|---|
| Allotted amount | Paid | Balance | Un-Reimbursed amount | |
|---|---|---|---|---|
| Allotted amount | Paid | Balance | Un-Reimbursed amount | |
|---|---|---|---|---|
Claim eligibility for payment is determined at the time your claim is processed. The amount payable is based on and not limited to your plan design, deductibles, percentage paid by your benefits, maximums, coordination of benefits, etc. For more details, refer to your benefit booklet or contact our Customer Response Centre.
| Benefit | |
|---|---|
| Balance is as of Midnight (EST). Claims processed today will be reflected on the next business day. |
Claim eligibility for payment is determined at the time your claim is processed. The amount payable is based on and not limited to your plan design, deductibles, percentage paid by your benefits, maximums, coordination of benefits, etc. For more details, refer to your benefit booklet or contact our Customer Response Centre.
| Procedure Description | Eligible | Deductible | eClaim Type | Eligible Amount |
|---|
| Copay Per Claim | Visit |
To a Maximum
|
|---|
| Maximum | Accumulated | Remaining |
|---|
| Frequency | Accumulated | Remaining |
|---|
Claim eligibility for payment is determined at the time your claim is processed. The amount payable is based on and not limited to your plan design, deductibles, percentage paid by your benefits, maximums, coordination of benefits, etc. For more details, refer to your benefit booklet or contact our Customer Response Centre.
| DIN | Drug Name | Deductible | eClaim Type | Co-Insurance | Specialty Support | Mail Order |
|---|
| ValueHealth | Effective Date | Terminated Date |
|---|
| Special Requirement |
|---|
| Maximum | Accumulated | Remaining |
|---|
| Quantity | Accumulated | Remaining |
|---|
Claim eligibility for payment is determined at the time your claim is processed. The amount payable is based on and not limited to your plan design, deductibles, percentage paid by your benefits, maximums, coordination of benefits, etc. For more details, refer to your benefit booklet or contact our Customer Response Centre.
| Category | Sub Category | Eligible | Referral Required | eClaim Type | Eligible Amount |
|---|
| Copay Per Claim | Visit |
To a Maximum
|
|---|
| Maximum | Accumulated | Remaining |
|---|
| Frequency | Accumulated | Remaining |
|---|
