Demo, Member
FSA Claim # 1234567895
Patient Name
Member DEMO
Date of Service
05/06/2018
Date Received
05/12/2018
Amount Submitted
$300.00
Processed
- 05/25/2018
FSA Paid
$120.00
Processed
- 05/25/2018
Amount Pending
$0.00
Medical
$300.00
$120.00
02/14/2018
7891234567
$0.00
Service Description:
Office visits
Claim Codes:
UG* Your network physician or health care provider has agreed to the plan discount. The discount shown is your savings for using a network physician or health care provider. You have not met your deductible and owe the amount shown.