Report ID : MIR310

Run Date : 12/27/2016 10:00 am

BATCHES BY PROVIDER Run By : YAHYA

Branch From : --All-- Branch To : --All--

Department From : --All-- Department To : --All--

Provider From : SHIFAA JEDDAH POLYCLINIC Provider To : SHIFAA JEDDAH POLYCLINIC

Treatment Period From : 08 - Aug / 2016 Treatment Period To : 08 - Aug / 2016

Service Provider : PC297-SHIFAA JEDDAH POLYCLINIC Account No : 1201400582

Sl No. Batch No. Batch Month /year Policy No. Policy Holder Gross Amount Rejection Outstanding Net Payable

1 164327 Aug/ 2016 3/2/1/508 263598-Dallah for Maint. & cont. Est. 4,886.30 256.79 0.00 4,629.51

2 164326 Aug/ 2016 1/1/1/538 95-Specialized Medical Center Hospital 1,144.45 409.43 0.00 735.02

3 164325 Aug/ 2016 1/2/1/515 3-Almarai Company 416.12 0.00 0.00 416.12

Provider Total : 6,446.87 666.22 0.00 5,780.65

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 Run Date : 12/27/2016 10:01 am
REJECTION REPORT Run By : YAHYA

Branch From : --All-- Branch To : --All--

Department From : --All-- Department To : --All--

Claim Type : 100 - DIRECT BILLING Batch No. From : --All-- To : --All--

Provider From : SHIFAA JEDDAH POLYCLINIC Provider To : SHIFAA JEDDAH POLYCLINIC

Period From : 08 - Aug - 2016 Period To : 08 - Aug - 2016

SHIFAA JEDDAH POLYCLINIC

Rejected
Sl No. Claim No. File No. Member Name Batch No. Policy No. Policy Holder Trtmnt Date Diagnosis Rejected Service Rejected Reason Rej. Type
Amount

1 C/233560 SHANTHA . KUMARA 164326 1/1/1/538 95-Specialized Medical 04/08/2016 I10-Essential (primary) LO59-CHOLESTEROL TOTAL 21.00 Pre-Authorization is Technical
Center Hospital hypertension required.

2 C/233560 SHANTHA . KUMARA 164326 1/1/1/538 95-Specialized Medical 04/08/2016 I10-Essential (primary) L084-TRIGLYCERIDES 30.00 Pre-Authorization is Technical
Center Hospital hypertension required.

3 C/233560 SHANTHA . KUMARA 164326 1/1/1/538 95-Specialized Medical 04/08/2016 I10-Essential (primary) L062-CREATININE 27.00 Pre-Authorization is Technical
Center Hospital hypertension required.

4 C/233560 SHANTHA . KUMARA 164326 1/1/1/538 95-Specialized Medical 04/08/2016 I10-Essential (primary) L079-SGOT (AST) 27.00 Pre-Authorization is Technical
Center Hospital hypertension required.

5 C/233560 SHANTHA . KUMARA 164326 1/1/1/538 95-Specialized Medical 04/08/2016 I10-Essential (primary) L080-SGPT (ALT) 35.00 Pre-Authorization is Technical
Center Hospital hypertension required.

6 C/233560 SHANTHA . KUMARA 164326 1/1/1/538 95-Specialized Medical 04/08/2016 I10-Essential (primary) L069-HDL CHOLESTEROL 45.00 Pre-Authorization is Technical
Center Hospital hypertension required.

7 C/233560 SHANTHA . KUMARA 164326 1/1/1/538 95-Specialized Medical 04/08/2016 I10-Essential (primary) MEDASICO001-ALL 134.43 Pre-Authorization is Technical
Center Hospital hypertension MEDICATION required.

8 C/233560 SHANTHA . KUMARA 164326 1/1/1/538 95-Specialized Medical 04/08/2016 I10-Essential (primary) L063-FBS 15.00 Pre-Authorization is Technical
Center Hospital hypertension required.

9 C/233560 SHANTHA . KUMARA 164326 1/1/1/538 95-Specialized Medical 04/08/2016 I10-Essential (primary) L086-URIC ACID 30.00 Pre-Authorization is Technical
Center Hospital hypertension required.

10 C/233560 SHANTHA . KUMARA 164326 1/1/1/538 95-Specialized Medical 04/08/2016 I10-Essential (primary) L071-LDL CHOLESTEROL 45.00 Pre-Authorization is Technical
Center Hospital hypertension required.

11 C/233917 GAUSAL AZAM ABDUL 164327 3/2/1/508 263598-Dallah for Maint. & 01/08/2016 E11.4-Type 2 diabetes 0.63 Deductible Recovery Technical
KHALEK cont. Est. mellitus with neurological
complication

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 12 C/233952 GAUSAL AZAM ABDUL 164327 3/2/1/508 263598-Dallah for Maint. & 02/08/2016 E11.4-Type 2 diabetes 8.03 Deductible Recovery Technical
KHALEK cont. Est. mellitus with neurological
complication

13 C/233969 GAUSAL AZAM ABDUL 164327 3/2/1/508 263598-Dallah for Maint. & 14/08/2016 E11.4-Type 2 diabetes ASCICOMED-3925-NOVOMIX 180.20 NOVOMIX FLEXPEN Technical
KHALEK cont. Est. mellitus with neurological 30 FLEXPEN 100U\ML30, INJ
complication 70ml5(SR189)

14 C/234209 MD.AMAN ULLAH 164327 3/2/1/508 263598-Dallah for Maint. & 27/08/2016 L23-Allergic contact A01-INJECTION CHARGE 13.92 Invalid Service Code Technical
MD.MOJIBUR RAHMAN cont. Est. dermatitis Chosen

15 C/234310 MOHAMMAD ALI MD 164327 3/2/1/508 263598-Dallah for Maint. & 30/08/2016 K02-Dental caries DN002-DENTAL X - RAY 30.00 Invalid Service Code Technical
JALAL UDDIN cont. Est. (RADIOGRAPH) Chosen

16 C/234693 THAJUDEEN SEIYADU 164327 3/2/1/508 263598-Dallah for Maint. & 10/08/2016 E78-Disorders of lipoprotein 0.01 Deductible Recovery Technical
RBIAHIM cont. Est. metabolism and other
lipidaemias

17 C/235044 No Card Member 164327 3/2/1/508 263598-Dallah for Maint. & 21/08/2016 1000-Undefined diagnosis C003-CONSULTATION GP 12.00 Price List Difference Technical
cont. Est. No card member is
chosen.

18 C/235052 No Card Member 164327 3/2/1/508 263598-Dallah for Maint. & 21/08/2016 1000-Undefined diagnosis C003-CONSULTATION GP 12.00 Price List Difference Technical
cont. Est. No card member is
chosen.

PROVIDER TOTAL : 666.22

Common Comment : Medical Rejection : 0.00

*** Kindly Note the medical rejection only negotiable with in 45 days following Receiving date of report.
Technical Rejection : 666.22

Total Rejection : 666.22

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