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Dear Faizal Mohammed Optometrists, Please find below a summary
of the remittances attached to this document. The summary includes
abreakdown of each medical aid and administration costs. Should any
of the following be unclear, please do not hesitate to contact the
Preferred Provider Call Centre forassistance
All the transactions, on the attached remittance, marked with an
asterisk (*) are NOT paid due to credits forthat specific medical
aid. Please refer to previous remittances. The transactions not
marked are summarizedby this coversheet and will be paid to your
practice.
FAIZAL MOHAMMED OPTOMETRISTS (7016085)P O BOX
2248NEWCASTLEKWAZULU NATAL2940
Preferred Provider NegotiatorsPO Box 12450
Centrahil6006
Tel: (041) 506-5900Fax: (041) 506-5750
Email: [email protected] Centre: 086 110 1477
STATEMENT 735
DATE 18/06/2013
Practice Payments Invoice Medical Patient Discount Settlement
Paid
Bestmed R5,031.00 R1,170.00 R3,861.00 R0.00 R150.00
R1,020.00
Bonitas R4,560.00 R3,730.00 R830.00 R0.00 R450.00 R3,280.00
Carecross Remedi R830.00 R830.00 R0.00 R0.00 R150.00 R680.00
Polmed R4,010.00 R4,010.00 R0.00 R0.00 R300.00 R3,710.00
Total R14,431.00 R9,740.00 R4,691.00 R0.00 R1,050.00
R8,690.00
Member Payments Invoice Medical Patient Discount Settlement
Paid
Total R0.00 R0.00 R0.00 R0.00 R0.00 R0.00
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PRACTICE 7016085
STATEMENT 735
DATE 18/06/2013
#2045257 - THEMBELIHLE N MANGELE (REF# 18620 - Acc# 18620)
18/06/2013Additional Rejection Codes: 24, 25 Preferred Provider
Transaction #4861642
Qty Code Description Rej # Invoice Medical Patient Discount
Settlement Paid1 70001 EXAM R400.00 R400.00 R0.00 R0.00 R0.00
R400.001 61125 M/F 25 R570.00 R310.00 R260.00 R0.00 R0.00 R310.001
61125 M/F 25 R570.00 R310.00 R260.00 R0.00 R0.00 R310.001 61625
HARD COAT 24 R149.00 R0.00 R149.00 R0.00 R0.00 R0.001 61625 HARD
COAT 24 R149.00 R0.00 R149.00 R0.00 R0.00 R0.001 61825 F/TINT 24
R209.00 R0.00 R209.00 R0.00 R0.00 R0.001 61825 F/ TINT 24 R209.00
R0.00 R209.00 R0.00 R0.00 R0.001 63725 SUMMIT CD 24 R600.00 R0.00
R600.00 R0.00 R0.00 R0.001 63725 SUMMIT CD 24 R600.00 R0.00 R600.00
R0.00 R0.00 R0.001 70405 FRAME 25 R1,575.00 R150.00 R1,425.00 R0.00
R150.00 R0.00
R5,031.00 R1,170.00 R3,861.00 R0.00 R150.00 R1,020.00
Page 1 of 1
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PRACTICE 7016085
STATEMENT 735
DATE 18/06/2013
#27703730320 - NOMUSA CECILIA MATIWANE (REF# 28175 - Acc#28175)
13/06/2013
Additional Rejection Codes: None Preferred Provider Transaction
#4858556
Qty Code Description Rej # Invoice Medical Patient Discount
Settlement Paid1 70001 EXAM R400.00 R400.00 R0.00 R0.00 R0.00
R400.001 61121 LENS R140.00 R140.00 R0.00 R0.00 R0.00 R140.001
61121 LENS R140.00 R140.00 R0.00 R0.00 R0.00 R140.001 70406 FRAME
R150.00 R150.00 R0.00 R0.00 R150.00 R0.00
R830.00 R830.00 R0.00 R0.00 R150.00 R680.00
#02023904473 - GERHARDUS P GELDENHUYS (REF# 11264 - Acc#11264)
13/06/2013
Additional Rejection Codes: None Preferred Provider Transaction
#4858998
Qty Code Description Rej # Invoice Medical Patient Discount
Settlement Paid1 61124 LENS R310.00 R310.00 R0.00 R0.00 R0.00
R310.001 61124 LENS R310.00 R310.00 R0.00 R0.00 R0.00 R310.001
70405 FRAME R600.00 R600.00 R0.00 R0.00 R150.00 R450.00
R1,220.00 R1,220.00 R0.00 R0.00 R150.00 R1,070.00
#02002815208 - KESHVEER SINGH (REF# 24984 - Acc# 24984)
15/06/2013Additional Rejection Codes: None Preferred Provider
Transaction #4860692
Qty Code Description Rej # Invoice Medical Patient Discount
Settlement Paid1 70001 EXAM R400.00 R400.00 R0.00 R0.00 R0.00
R400.001 61121 S/V R140.00 R140.00 R0.00 R0.00 R0.00 R140.001 61121
S/V R140.00 R140.00 R0.00 R0.00 R0.00 R140.001 70405 FRAME R600.00
R600.00 R0.00 R0.00 R150.00 R450.00
R1,280.00 R1,280.00 R0.00 R0.00 R150.00 R1,130.00
#27703179015 - THOMAS JAMES DREYER (REF# 25370 - Acc# 25370)
15/06/2013Additional Rejection Codes: 25 Preferred Provider
Transaction #4860673
Qty Code Description Rej # Invoice Medical Patient Discount
Settlement Paid1 70001 EXAM 25 R400.00 R0.00 R400.00 R0.00 R0.00
R0.001 61121 S/V 25 R140.00 R0.00 R140.00 R0.00 R0.00 R0.001 61121
S/V 25 R140.00 R0.00 R140.00 R0.00 R0.00 R0.001 70405 FRAME 25
R150.00 R0.00 R150.00 R0.00 R0.00 R0.00
R830.00 R0.00 R830.00 R0.00 R0.00 R0.00
#02024939100 - JAICHUND HARIPARSAD THULASEE (REF# 6490 -
Acc#6490) 18/06/2013
Additional Rejection Codes: None Preferred Provider Transaction
#4861601
Qty Code Description Rej # Invoice Medical Patient Discount
Settlement Paid1 70001 EXAM R400.00 R400.00 R0.00 R0.00 R0.00
R400.00
R400.00 R400.00 R0.00 R0.00 R0.00 R400.00
Page 1 of 1
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PRACTICE 7016085
STATEMENT 735
DATE 18/06/2013
#415780220 - AYESHA TIMOL (REF# 13560 - Acc# 13560)
13/06/2013Additional Rejection Codes: None Preferred Provider
Transaction #4858587
Qty Code Description Rej # Invoice Medical Patient Discount
Settlement Paid1 70001 EXAM R400.00 R400.00 R0.00 R0.00 R0.00
R400.001 61121 LENS R140.00 R140.00 R0.00 R0.00 R0.00 R140.001
61121 LENS R140.00 R140.00 R0.00 R0.00 R0.00 R140.001 70405 FRAME
R150.00 R150.00 R0.00 R0.00 R150.00 R0.00
R830.00 R830.00 R0.00 R0.00 R150.00 R680.00
Page 1 of 1
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PRACTICE 7016085
STATEMENT 735
DATE 18/06/2013
#000149717 - KENNETH MNQAYI (REF# 24592 - Acc# 24592)
13/06/2013Additional Rejection Codes: None Preferred Provider
Transaction #4858613
Qty Code Description Rej # Invoice Medical Patient Discount
Settlement Paid1 70001 EXAM R400.00 R400.00 R0.00 R0.00 R0.00
R400.001 61125 LENS R570.00 R570.00 R0.00 R0.00 R0.00 R570.001
61125 LENS R570.00 R570.00 R0.00 R0.00 R0.00 R570.001 70405 FRAME
R900.00 R900.00 R0.00 R0.00 R150.00 R750.00
R2,440.00 R2,440.00 R0.00 R0.00 R150.00 R2,290.00
#000126705 - ZANELE HADEBE (REF# 29224 - Acc# 29224)
13/06/2013Additional Rejection Codes: None Preferred Provider
Transaction #4858573
Qty Code Description Rej # Invoice Medical Patient Discount
Settlement Paid1 70001 EXAM R400.00 R400.00 R0.00 R0.00 R0.00
R400.001 61121 LENS R140.00 R140.00 R0.00 R0.00 R0.00 R140.001
61121 LENS R140.00 R140.00 R0.00 R0.00 R0.00 R140.001 70405 FRAME
R890.00 R890.00 R0.00 R0.00 R150.00 R740.00
R1,570.00 R1,570.00 R0.00 R0.00 R150.00 R1,420.00
Page 1 of 1
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PRACTICE 7016085
STATEMENT 735
DATE 18/06/2013
Herewith please find a list of rejection codes and their
descriptions pertaining to the above mentioned claims
Code Description
24 Item / service is not covered by the insured benefit
25 Benefit Exceeded / Exhausted