John Smith
Patient ID: PAT-5678
Insurance Provider
Aetna Dental
Member ID
ATN123456789
Group Number
GRP987654
Plan Type
PPO
Verification Details
Verification Date
June 1, 2023 at 10:30 AM
Verified By
System
Sleep Apnea Evaluation
Appointment ID: APT-1234
Date
June 20, 2023
Time
10:30 AM
Preventive Care
100%
Basic Services
80%
Major Services
50%
Orthodontic
50%
Sleep Apnea Treatments
80%
Annual Maximum
$1500
Used Benefit
$300
Remaining Benefit
$1200
Deductible
$50 (Met)
Sleep apnea oral appliances covered with prior authorization.