Sample Blank Billing Statement

Premium Invoice
Page 1
SAMPLE A - 600
MemberID Name Med Drug Vision
HDS
Dental
ACA
Fee
Total
9901000106
Detail Premium Statement for:
Group and Division #:
Invoice Date: 12/10/2013
Current Billing Period: 01/01/2014 to 01/31/2014
Benefits: Plan 600
Contract
Type
SAMPLE BILL - A
099010001
Member
Count
SAMPLE A
SAMPLE ASAMPLE A
SAMPLE A
UHA 600 - 9901000106
Current Charges:
990100103 AFAMILY, SUBSCRIBER $915.75$120.00 $15.75$30.00$150.00$600.00F 3
990100101 ASINGLE, SUBSCRIBER $305.25$40.00 $5.25$10.00$50.00$200.00S 1
990100102 ATWOPARTY, SUBSCRIB $610.50$80.00 $10.50$20.00$100.00$400.00T 2
Subtotal: $1,200.00 $1,831.50$240.00 $31.50$60.00$300.00 6
Totals:
$1,200.00
$60.00
$300.00
Summary of Contracts
for Plan:
Single
Two Party
Family
1
1
1
UHA 600
Medical
Drug
Vision
$1,831.50
$240.00
$31.50ACA Fee
HDS Dental
Total:UHA 600
$1,200.00
$60.00
$300.00
Medical
Drug
Vision
$1,831.50
$240.00
$31.50ACA Fee
HDS DentalSummary of Contracts
for Plan(s):
Single
Two Party
Family
1
1
1
PREMIUM BILL RECONCILIATION
Terminations:
Employee Name Member ID # Termination Date Amount
( . )
( . )
.
.
Additions:
Employee Name Social Security # Effective Date Amount
Total Subtractions:
( . )
Total Additions:
.
Payment Amount Submitted:
.
Date
(Completed Enrollment Forms MUST be attached)
Changes will NOT be processed without authorized signature and date
Important:
Group Administrator Signature:
Current Billing
Period Totals:
Total Current Month and Retroactive Charges:
Note: Use this section for corrections to the Current Billing Period ONLY
For questions regarding eligibility changes, terminations, or additions, call Enrollment at
(808) 532-4007 from Oahu, or (800) 458-4600, ext. 299 from the neighbor islands.
Page 2/9
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