| Insured Name | Policy No | Payment Status | Claim No | Transaction No | In Payment Of | Payee Name | Summary Amount |
|---|---|---|---|---|---|---|---|
| MRS. EA MOUYKIM AND ON THE LIVES OF HER FAMILY MEMBER | CHC/PPI/C-1110 |
Full Payment | CL/CHC/PPI/21173 | CL/CHC/PPI/21173-01 |
OUT-PATIENT | RATHA CHEA | 33.75 |
| Account Code | Account Name | Debit | Credit |
|---|---|---|---|
111013 |
Claim Paid-Medical Exp. | 33.75 | 0.00 |
660020 |
Amount due from/(TO)Reinsuranc | 10.13 | 0.00 |
115513 |
Claim Rec.Cam.Re- Medical Exp | 0.00 | 10.13 |
113413 |
Claim Rec.Out FAC-Medical | 0.00 | 0.00 |
114013 |
Claim Rec.Q.T Share-Medical | 0.00 | 0.00 |
660216 |
ABA - Collection Acct | 0.00 | 33.75 |