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Claim Status for: JOHN DOE

Reference Number :   0430233700018 Date(s) of Service:   01/02/2002 Date Processed:   2/05/2002
 
Service Provider(s):   UCLA DENTAL CLINIC  


  Type of
Service 		Tooth
Number 		 Date(s) of
Service		 Charge
Amount		 Not Covered 
Amount		 Deductible 
Applied		 Covered
Balance		 CIGNA
Coinsurance		 Member
Coinsurance		 Remark
Code(s)
  Tooth extraction 06 01/02/2002 $398.63 $0.00   $50.00   $348.63   80% = $278.90 20% = $69.73 0102

The information above reflects our data at the time your claim was processed; it may not show the final member coinsurance amount due to ongoing claims processing activities such as the payment of additional claims before this claim is paid or an adjustment to this claim. Your EOB will reflect the final member responsibility.
 
Payment Information
CIGNA Paid Amount: $278.90
Paid To: UCLA DENTAL CLINIC
Payee's Address: PO BOX 357662
  LOS ANGELES, CA 90095
Check Number: 630362196
   
   
Provider checks that indicate a paid amount greater than the paid amount listed in the details above indicate a bulk payment made to that provider that will include payments for other claims.
Explanation of Remark Codes
0102 $0.00 BASED ON INFORMATION REPORTED OR IN FILE, A DIFFERENT PROCEDURE CODE (AS SHOWN) HAS BEEN ASSIGNED.
 




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