Explanation of Benefits
Risk Carrier : LIBANO SUISSE Policy Holder Name : EMC- San Masr
Member : 50007228 50015477 Staff # : 004855-01 Provider : Al Mokhtabr Laboratories - Roxy 1
Claim Number : 17959567
MCN : 23099488 Batch # : 0
Principal Name : MAHMOUD M IBRAHIM
Name : MAHMOUD IBRAHIM
Date Of Birth : 1984
Transaction Date : 11/04/2019 Invoice Number : Physician : Nozha International Hospital Default Doctor
Detailed Bill Med File : Cons. Fees : 0.00 EGP SSNBR : 30306300
Service Item Unit Price Type Qty Claimed Curr Total Claimed Qty Appr. Total Appr. Disc.
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 2
Explanation of Benefits
Risk Carrier : LIBANO SUISSE Policy Holder Name : EMC- San Masr
Member : 50007228 50015477 Staff # : 004855-01 Provider : Al Mokhtabr Laboratories - Roxy 1
Claim Number : 17959567
MCN : 23099488 Batch # : 0
Principal Name : MAHMOUD M IBRAHIM
Name : MAHMOUD IBRAHIM
Date Of Birth : 1984
Transaction Date : 11/04/2019 Invoice Number : Physician : Nozha International Hospital Default Doctor
Service Item Unit Price Type Qty Claimed Curr Total Claimed Qty Appr. Total Appr. Disc.
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 2 of 2