HSA Claims for Previous Year in Service Date Order
Plan member: Candy Barr
Certificate number: 1234567
Print
Service recipient
Birth year
Service date
Benefit
Billed
amount
Other plan
paid amount
Paid
amount
Credits used
benefit year
Processed
Status
Explanation Code
BILL
1973
Apr 14 2020
PRESCRIPTION DRUG
23.79
20.16
3.54
201904
Apr 15 2020
Processed
Apr 25 2020
PRESCRIPTION DRUG
35.30
29.42
5.88
201904
Apr 27 2020
Processed
May 5 2020
CHIROPRACTOR
50.00
40.00
10.00
202004
May 08 2020
Processed
May 07 2020
CHIROPRACTOR
50.00
40.00
10.00
202004
May 11 2020
Processed
May 14 2020
CHIROPRACTOR
50.00
40.00
10.00
202004
May 18 2020
Processed
May 19 2020
CHIROPRACTOR
50.00
40.00
10.00
202004
May 22 2020
Processed
May 25 2020
PRESCRIPTION DRUG
50.00
40.00
10.00
202004
May 27 2020
Processed
May 26 2020
PRESCRIPTION DRUG
35.30
29.42
5.88
202004
May 29 2020
Processed
June 02 2020
CHIROPRACTOR
50.00
40.00
10.00
202004
Jun 05 2020
Processed
Jun 09 2020
PRESCRIPTION DRUG
83.38
67.90
15.48
202004
Jun 12 2020
Processed
Jun 23 2020
CHIROPRACTOR
83.38
67.90
15.48
202004
Jun 24 2020
Processed
Jun 23 2020
PRESCRIPTION DRUG
35.30
29.42
5.88
202004
Jun 26 2020
Processed
Jul 23 2020
PRESCRIPTION DRUG
155.75
10.50
145.25
202004
Jul 24 2020
Processed
Jul 24 2020
PRESCRIPTION DRUG
35.30
29.42
5.88
202004
Jul 27 2020
Processed
Aug 19 2020
MASSAGE THERAPY - 46 - 60 MINS
35.30
29.42
5.88
202004
Aug 21 2020
Processed
Aug 22 2020
PRESCRIPTION DRUG
155.75
0.00
155.75
202004
Aug 24 2020
Processed
Aug 22 2020
PRESCRIPTION DRUG
35.30
29.42
5.88
202004
Aug 24 2020
Processed
Aug 26 2020
MASSAGE THERAPY - 46 - 60 MINS
35.30
29.42
5.88
202004
Aug 28 2020
Processed
Sep 02 2020
MASSAGE THERAPY - 46 - 60 MINS
155.75
0.00
155.75
202004
Sep 04 2020
Processed
Sep 21 2020
PRESCRIPTION DRUG
35.30
29.42
5.88
202004
Sep 23 2020
Processed
Oct 10 2020
PRESCRIPTION DRUG
42.61
35.29
7.32
202004
Oct 12 2020
Processed
Oct 10 2020
PRESCRIPTION DRUG
54.57
44.86
9.71
202004
Oct 12 2020
Processed
Oct 21 2020
EYE EXAM - OPTOMETRIST
54.57
44.86
9.71
202004
Oct 23 2020
Processed
Oct 21 2020
FRAMES
12.98
11.58
1.40
202004
Oct 23 2020
Processed
Nov 20 2020
PRESCRIPTION DRUG
64.86
53.09
11.77
202004
Nov 23 202
Processed
Dec 07 2020
PRESCRIPTION DRUG
92.44
75.15
17.29
202004
Dec 09 2020
Processed
Jan 06 2021
PRESCRIPTION DRUG
12.98
11.58
1.40
202004
Apr 14 2020
Processed
Jan 14 2021
PRESCRIPTION DRUG
42.61
35.29
7.32
202004
Jan 07 2021
Processed
Feb 05 2021
PRESCRIPTION DRUG
54.57
44.86
9.71
Expired
277
Feb 11 2021
PRESCRIPTION DRUG
12.98
11.58
1.40
Expired
277
Mar 06 2021
CHIROPRACTOR
92.44
75.15
17.29
Expired
277
Mar 16 2021
PRESCRIPTION DRUG
92.44
75.15
17.29
Expired
277
Mar 18 2021
CHIROPRACTOR
42.61
35.29
7.32
Expired
277
Mar 18 2021
CHIROPRACTOR
42.61
35.29
7.32
Expired
277
Mar 25 2021
CHIROPRACTOR
42.61
35.29
7.32
Expired
277
Mar 30 2021
CHIROPRACTOR
42.61
35.29
7.32
Expired
277
CANDY
1960
Apr 08 2020
PRESCRIPTION DRUG
42.61
35.29
7.32
201904
Processed
Apr 08 2020
PRESCRIPTION DRUG
54.57
44.86
9.71
201904
Processed
Apr 29 2020
PRESCRIPTION DRUG
90.93
73.94
16.99
201904
Processed
Apr 29 2020
PRESCRIPTION DRUG
47.18
38.94
4.36
201904
Processed
131
April 29 2020
PRESCRIPTION DRUG
0.00
0.00
3.88
202004
Processed
131
May 22 2020
PRESCRIPTION DRUG
54.57
0.00
3.88
202004
Processed
131
May 22 2020
PRESCRIPTION DRUG
47.18
44.86
9.71
202004
Processed
Jun 26 2020
PRESCRIPTION DRUG
42.61
14.74
7.32
202004
Processed
Jun 26 2020
PRESCRIPTION DRUG
54.57
14.74
9.71
202004
Processed
Jun 26 2020
PRESCRIPTION DRUG
16.93
14.74
2.19
202004
Processed
Jun 26 2020
PRESCRIPTION DRUG
62.28
51.02
11.26
202004
Processed
Aug 06 2020
PRESCRIPTION DRUG
42.61
35.29
7.32
202004
Processed
Aug 06 2020
PRESCRIPTION DRUG
42.61
35.29
7.32
202004
Processed
Sep 11 2020
PRESCRIPTION DRUG
42.61
35.29
7.32
202004
Processed
Sep 11 2020
PRESCRIPTION DRUG
42.61
35.29
7.32
202004
Processed
Oct 16 2020
PRESCRIPTION DRUG
42.61
35.29
7.32
202004
Processed
Oct 16 2020
PRESCRIPTION DRUG
42.61
35.29
7.32
202004
Processed
Nov 19 2020
PRESCRIPTION DRUG
42.61
35.29
7.32
202004
Processed
Nov 24 2020
PRESCRIPTION DRUG
42.61
35.29
7.32
202004
Processed
Nov 24 2020
PRESCRIPTION DRUG
42.61
35.29
7.32
202004
Processed
Dec 09 2020
PRESCRIPTION DRUG
42.61
35.29
7.32
202004
Processed
Dec 28 2020
PRESCRIPTION DRUG
42.61
35.29
7.32
202004
Processed
Jan 05 2021
PRESCRIPTION DRUG
42.61
35.29
7.32
202004
Processed
Jan 05 2021
PRESCRIPTION DRUG
42.61
35.29
7.32
202004
Processed
Feb 22 2021
PRESCRIPTION DRUG
54.57
44.86
0.00
Expired
277
Feb 22 2021
PRESCRIPTION DRUG
54.57
44.86
0.00
Expired
277
Feb 22 2021
PRESCRIPTION DRUG
54.57
44.86
0.00
Expired
277
Total paid
Total billed amount
Total other plans paid amount
$602.30
$1979.11
$1376.81
Explaination codes
‍
277
‍
131
The expenses submitted exceed the credits available under this plan. No further credits will accrue
Benefits have been coordinated with another plan.