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Plan Information - Coverage and Deductible
    IN OUT
Procedure Category Procedure Category Description Coverage Deductible Applies Waiting Period Met Date Coverage Deductible Applies Waiting Period Met Date
Plan Information - Deductible
  IN OUT
Description Member Amount Family Amount Member Amount Family Amount
Plan Information - Limit
  IN OUT
Description Member Limit Amount Family Limit Amount Member Limit Amount Family Limit Amount
Amount of Limit Met
  IN OUT
Limit Description Member Limit Amount Family Limit Amount Member Limit Amount Family Limit Amount
Rollover Benefit
Benefit Year Maximum:
Benefit Year Award Received:
Benefit Year Bonus Received:
Benefit Year Maximum Paid Toward Award:
Benefit Year Award Used:
Benefit Year Bonus Used:
Benefit Year Award Balance:
Benefit Year Bonus Balance:
Utilization
ADA Code ADA Description Procedure Category Service Dates Service Date Procedure Code Frequency* (i-ii-iii) Age Limit Alternate Benefit Related Codes
* Frequency Definition: i = Number of Procedure (999 = unlimited); ii = ProcedureFrequency Type (C=Calendar Year, F=Floating, P=Plan Year); iii = Period and Timeframe(D=Day, M=Month, Y=Year) Example: 1 F 36M read as 1 Procedure per 36 Floating Months

Claims Address Payor Id:
521337971