Specific Claims Paid to Date

Effective

Policy effective date.

Policyholder

Policy holder name.

Claimant

Who made the claim.

Diagnosis

Patient diagnosis.

C/B

Policy contract basis.

Incurred From

First date of treatment covered by the claim.

Incurred To

Last date of treatment covered by the claim.

Paid From

When the first payment was made on the claim.

Paid To

When the last payment was made on the claim.

TPA Paid Claims

Amount paid on the claim by the third party administrator.

Deductible

Policy deductible.

Denied/ Pending

Claim amount either denied or pending.

Reimburse

Reimbursement amount.

Outstanding

Payment amount still outstanding.

Reserves

Reserve amount on the claim.