30/10/2017

Explanation of Benefits
Risk Carrier : AROPE EGYPT Policy Holder Name : PROSERV
Member : 50003250 50467939 Staff # : 127 Provider : El Agaebyia Center for Physiotherapy 2
Claim Number :
MCN : 15703271 Batch # : 0
Principal Name : MOHAMED H AHMED
Name : MOHAMED AHMED
Date Of Birth : 1991

Transaction Date : 30/10/2017 Invoice Number : Physician : Default Doctor

Diagnosis : Arthritis, unspecified, site unspecified Approved by Mahmoud Gamal

Detailed Bill Med File : Cons. Fees : 0.00 EGP SSNBR : 22628862

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

Physiotherapy & 1- 30.00 6 EGP 180.00 6 180.00 0.00

rehabilitation

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 1