| Invoice Number: | 148348 |
| Reconciliation Period: | 01/01/2007 - 01/31/2007 |
| Master Number: | 03000-00 |
| Group Number: | 93705-000-00000-00000 |
| Description: | |
| Phone Number: | (999) 999-0000 |
| SELF INSURED |
| BENEFITS ADMINISTRATOR |
| 321 UNIVERSITY AVENUE |
| ANYWHERE, USA 55555-0000 |
| CLAIM PAYMENT INFORMATION |
|---|
| DOS | Billed Amount | Paid Claims |
|---|
| 11/27/2006 | $ | 169.00 | | $ | 120.00 | |
| 07/01/2006 | $ | 820.00 | | $ | 274.00 | |
| 12/27/2006 | $ | 133.00 | | $ | 97.50 | |
| 01/11/2007 | $ | 106.00 | | $ | 79.00 | |
| 01/09/2007 | $ | 236.00 | | $ | 149.80 | |
| 01/09/2007 | $ | 196.00 | | $ | 141.00 | |
| 01/04/2007 | $ | 179.00 | | $ | 131.25 | |
| 01/18/2007 | $ | 390.00 | | $ | 170.00 | |
| 01/04/2007 | $ | 829.00 | | $ | 378.00 | |
| 01/18/2007 | $ | 24.00 | | $ | 16.50 | |
| 01/11/2007 | $ | 153.00 | | $ | 106.50 | |
| 12/28/2006 | $ | 163.00 | | $ | 23.50 | |
| 01/08/2007 | $ | 179.00 | | $ | 57.60 | |
| 01/16/2007 | $ | 95.00 | | $ | 79.00 | |
| 01/15/2007 | $ | 340.00 | | $ | 122.50 | |
| 01/15/2007 | $ | 35.00 | | $ | 30.00 | |
| 01/15/2007 | $ | 68.00 | | $ | 58.00 | |
| 12/19/2006 | $ | 32.00 | | $ | .00 | |
| 12/19/2006 | $ | 80.00 | | $ | .00 | |
| 12/20/2006 | $ | 110.00 | | $ | 73.50 | |
| 01/22/2007 | $ | 92.00 | | $ | 77.00 | |
| 01/03/2007 | $ | 98.00 | | $ | 72.00 | |
| 12/22/2006 | $ | 250.00 | | $ | 84.00 | |
| 11/27/2006 | $ | .00 | | $ | 88.00 | |
| 01/03/2007 | $ | 102.00 | | $ | .00 | |
| 01/25/2007 | $ | 204.00 | | $ | 72.00 | |
| 12/18/2006 | $ | 940.00 | | $ | 564.00 | |
| 01/19/2007 | $ | 155.00 | | $ | 104.25 | |
| 11/30/2006 | $ | 118.00 | | $ | 81.75 | |
| 12/15/2006 | $ | 135.00 | | $ | 67.50 | |
| 12/20/2006 | $ | 67.00 | | $ | 45.00 | |
| 11/27/2006 | $ | 644.00 | | $ | 386.40 | |
| 01/03/2007 | $ | 1,015.00 | | $ | 600.80 | |
| 01/15/2007 | $ | 90.00 | | $ | .00 | |
| 01/15/2007 | $ | 298.00 | | $ | .00 | |
| 12/28/2006 | $ | 232.00 | | $ | 72.00 | |
| 12/15/2006 | $ | 112.50 | | $ | 56.25 | |
| 01/06/2007 | $ | 106.00 | | $ | 81.00 | |
| |
| Claim Payments: | $ | 8,995.50 | | $ | 4,559.60 | |
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