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HSA Claims for Current Year in Service Date Order
HSA Claims for Previous Year in Service Date Order
HSA Claims Paid Using Current Year Credits
HSA Claims Paid Using Previous Year Credits
Plan member: -
Certificate number: -
Service recipient
Birth year
Service date
Benefit
Billed
amount
amount
Other plan
paid amount
paid amount
Paid
amount
amount
Credits used
benefit year
benefit year
Processed
Status
Explanation Code
-
-
-
-
-
-
-
-
-
-
-
Total paid
Total billed amount
Total other plans paid amount
-
-
-
Explanation codes
XXX - XXX