Sample Blank Billing Statement
Premium Invoice
Page 1
SAMPLE C - 3000
MemberID Name Med Drug Vision
HDS
Dental
ACA
Fee
Total
9903000303
Detail Premium Statement for:
Group and Division #:
Invoice Date: 12/10/2013
Current Billing Period: 01/01/2014 to 01/31/2014
Benefits: UHA 3000
Contract
Type
SAMPLE BILL - C
099030003
Member
Count
SAMPLE C
SAMPLE CSAMPLE C
SAMPLE C
UHA 3000 - 9903000303
Current Charges:
990300303 CFAMILY, SUBSCRIBER $915.75$120.00 $15.75$30.00$150.00$600.00F 3
990300301 CSINGLE, SUBSCRIBER $305.25$40.00 $5.25$10.00$50.00$200.00S 1
990300302 CTWOPARTY, 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
Retro Adjustments:
990300392 XFAMILY, SUBSCRIBER ($915.75)($120.00) ($15.75)($30.00)($150.00)($600.00)F -3
Subtotal: ($600.00) ($915.75)($120.00) ($15.75)($30.00)($150.00) -3
Totals:
$600.00
$30.00
$150.00
Summary of Contracts
for Plan:
Single
Two Party
Family
1
1
1
UHA 3000
Medical
Drug
Vision
$915.75
$120.00
$15.75ACA Fee
HDS Dental
Total:UHA 3000
$600.00
$30.00
$150.00
Medical
Drug
Vision
$915.75
$120.00
$15.75ACA 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 6/9
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