Welcome to your Monthly Claim Report
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1. Welcome To Your Claim Reconciliation. Below is the ORIGINAL benefit level you signed up for under Egyptian Trust. Your New HIGH DEDUCTIBLE PLAN at BCBS COMBINED WITH YOUR QPS DEDUCTIBLE REIMBURSEMENT PLAN WILL RECREATE THIS SAME BENEFIT USING YOUR NEW DEDUCTIBLE
Calendar Year:
2. Under the Egyptian Trust Plan you satisfied the following out of pocket amounts. Any category that is orange highlighted is MAXED OUT (if OOP is Maxed Individually or as Family ALL IN NETWORK CLAIMS WILL BE REIMBURSED 100%). BCBS on your new plan should have reduced your Deductible and Coinsurance by the amounts previously credited. BCBS must credit that carryover credit before we can reimburse.
| Calendar Year |
First Name |
Last Name |
Relationship |
Deductible |
Coinsurance |
Copay |
OOP Sum Ded Plus Coinsurance |
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3. Below is the family members that we received claims for. CLICK ON DETAILS to view the category of claim types they sent for each member. Only claims processed by the last day of the prior month are included.
| Plan year |
Name |
Total BCBS Billed |
Total BCBS Allowed |
Total BCBS Paid |
Total Due Provider |
Total Deductible Reimbursements |
Total Copay Reimbursements |
Total Employee Real Responsibility |
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| Plan year |
Name |
Total BCBS Billed |
Total BCBS Allowed |
Total BCBS Paid |
Total Due Provider |
Total Deductible Reimbursements |
Total Copay Reimbursements |
Total Employee Real Responsibility |
Admin Prior Copay |
Admin Prior Allowed |
Admin Prior Allowed RX |
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4. Displayed below is the Summation of Claims by Category for . CLICK DETAILS to see the actual claims and providers.
| Plan year |
Claim Description |
Name |
Total BCBS Billed |
Total BCBS Allowed |
Total BCBS Paid |
Total Due Provider |
Total Deductible Reimbursements |
Total Copay Reimbursements |
Total Employee Real Responsibility |
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Displayed below is the Detailed Break Down Of Claims Detected As New By The VIP Puller And Will Be Closed Out After BCBS Finalizes
| Processed Date |
Date of Service |
Name |
Claim Number |
Provider |
Total Billed |
Penalty |
Allowed Amount |
BCBS Paid |
Amount Due Provider |
Plan Year |
Claim Type |
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5. CLAIM DETAILS BY PERSON/CATEGORY/PROVIDER - We are in the process of marking the reimbursement due. Your claims are NOT FINALIZED if you dot see RED LETTERING "FINAL- ALL REIMBURSEMENTS ATTRIBUTED" BCBS was delayed in releasing claims-Check back in 48 hours to view our finalized report!
Claims for
Claim Type:
| Processed Date |
Date of Service |
Plan Year |
Name |
Claim Number |
Provider |
Claim Type |
Total Billed |
Penalty |
Allowed Amount |
BCBS Paid |
Amount Due Provider |
Total Deductible Reimbursements |
Total Copay Reimbursements |
Employee Real Responsibility |
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| Place Of Service |
Billed Amount |
Allowed Amount |
Carrier Paid |
Your Responsibility |
Primary Diagnosis |
Procedure Description |
Procedure Code |
Deductible |
Coinsurance |
Copay |
Penalty |
Medication Name |
Medication QTY |
Medication Supply |
LineId |
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