Reimbursement Spreadsheet with Deductible Template
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When Bill Is PaidDate of ServiceWhoDoctor, etc.WhatTotal ChargesHealth Plan PaysAmount we payCo-payReimb AmtHis DeductibleHer Deductible#1 Deductible#2 DeductibleMileageDate SubmittedDoneComments
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1/18/20181/18/2018HersRxOTC Rx$8.55$8.55$9.002/3/2018yes
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mileage$2.00$2.00122/3/2018yes
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2/3/2018$11.002/3/2018yes
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3/15/2018HisDr. Choocleaning$260.00$0.00$248.00nowaiting for dentist's bill
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mileage$1.00$1.006no
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2/27/20183/20/2018HisCareMarkRx$128.32$128.32$0.00$128.003/28/2018yes
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3/28/2018$128.003/28/2018yes
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7/8/2018HisDr. Whomigraine$155.00$0.00$30.00noEOB not received
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mileage$4.00$4.0024no
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1/24/20187/31/2018HersDr. WhoFU blood work$345.00$149.49$17.49$30.00$47.00$1.8612/12/2018pendingsubmitted, but not approved
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mileage$4.00$4.002412/12/2018pending
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12/12/2018$47.0012/12/2018pending
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TOTALS$907.87$277.81$60.00$443.00$0.00$1.86$0.00$0.00
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LINKSLink to online reimbursements
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Date calculator for ninety-day limits
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United Concordia (dental)His$1,500$0.00
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BlueCrossHers$1,500$1.86
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Caremark (Rx)#1?$0.00
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More healthcare benefits (Staff Web)#2?$0.00
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Family deductible$4,500$0.00
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CONTACT Staff Services
(888) CRU-7233, option 2, 2
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9:00 a.m. to 5:00 p.m. ET.
text questions to (872) 216-8398
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Monday - Friday
staff.services@cru.org
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