| Member SSN Claim Number |
Benefits Start |
Approved Through |
Status Reason |
|---|---|---|---|
| TIM BROWN xxx-00-1111 / 00010001 |
Newly Assigned | ||
| PAT CARTER xxx-00-2222 / 00020002 |
mm/dd/yyyy | mm/dd/yyyy |
| Member SSN Claim Number |
Benefits Start |
Approved Through |
Status Reason |
|---|---|---|---|
| BOB FRANKLIN xxx-00-1111 / 00010001 |
mm/dd/yyyy | mm/dd/yyyy | ANTICIPATED RECOVERY DATE |
| LINDA JONES xxx-00-2222 / 00020002 |
mm/dd/yyyy | mm/dd/yyyy | UPDATED MEDICAL NEEDED |
| JOHN SMITH xxx-00-3333 / 00030003 |
mm/dd/yyyy | mm/dd/yyyy | END OF BENEFIT PERIOD |
| Member SSN Claim Number |
Benefits Start |
Approved Through |
Status Reason |
|---|---|---|---|
| LOU LAWSON xxx-00-1111 / 00010001 |
mm/dd/yyyy | RECOVERED DURING THE BWP | |
| SARAH MANNING xxx-00-2222 / 00020002 |
mm/dd/yyyy | OTHER |
| Member SSN Claim Number |
Benefits Start |
Approved Through |
Status Reason |
|---|---|---|---|
| JANE BROOKS xxx-00-1111 / 00010001 |
ANTICIPATORY CLAIM | ||
| TOM PETERS xxx-00-2222 / 00020002 |
NEED PHYSICIAN STATEMENT | ||
| LARRY SMITH xxx-00-3333 / 00030003 |
NEED EMPLOYER/PHYSICIAN STATEMENTS |