Current Location: Delta Dental Home Page > Sample Explanation of Benefits
September 9, 2010
EXPLANATION
OF
BENEFITS

 

 

HARVEY J SCHNEIDER
100 MAIN STREET
STEVENS POINT WI 544810000		Patient:HARVEY J SCHNEIDER
Group No.93705-000-00000-00000
Claim No.0-6345-314-49
Check No.2603172
Payment Date:12/20/2006
DDS License No:333259162 USA 008

TTH#Date of ServiceProc. CodeDescriptionSubmitted Amount Approved AmountAllowed Amount% copay*
**		COBPatient PayDelta PayRef code
1812/06/0602140FILLING$107.00$85.00$85.0080-$.00$17.00$68.00-
 $17.00$68.00 
THIS IS NOT A BILLTotalTotal 

Check No:2603172Payment Date:12/20/2006
Payee Name:MIDWEST DENTAL CARE
Address:PO BOX 90
ANYWHERE USA 555550000

Voucher Explanation

Submitted Amount: The amount billed/charged for the procedure.

Approved Amount: The amount approved for total patient/Delta payment.

Allowed Amount: The allowed fee for the covered procedure used to calculate Delta's payment.

* = Exceeds Maximum: Indicates the service exceeds patient/group benefit year maximum.

** = Deductible: Indicates patient/group must meet deductible for all or a portion of the service.