3
Specific Audit Charges
Provider
Who is providing the care.
Svc From
Date care was first provided.
Svc To
Date care was last provided.
Admin Paid
Amount paid to the administrator.
Adjustments
Any adjustments to the claim amount.
Allowable
Amount qualifying for reimbursement.
Reimb %
Percentage of claim amount that will be reimbursed.
Reimbursable
Amount that will be reimbursed.