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Claim Status for:    JOHN DOE
Reference Number:    1234567890123 Date(s) Of Service:    09/17/2003 to 09/17/2003 Date Processed:    09/25/2003
 
Service Provider:   SUSAN BROWN
Type of
Service 		Date(s) of
Service 		Charge
Amount		 Not Covered
Amount		 Deductible/
Copay Applied 		Covered
Balance 		CIGNA
Coinsurance 		Member
Coinsurance 		Remark
Codes(s)
Physician Services Hospital 09/17/2003 $278.95 $.00 $.00/$.00 $278.95 90% = $251.05 10% = $27.90 Q2
 
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 Details
CIGNA Paid Amount: $251.05
Paid To: SUSAN BROWN MD
Payee's Address: FLASH PAN RD, MILLDALE, CT 06010
Check Number: 0066673496
Check Status: OUTSTANDING
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
Q2 - These services were rendered by a preferred provider.


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