December 2025 claims — Venus Medicare
Reconciliation · Batch — one provider · Venus Medicare Limited
Where the deduction sits
The three are not the same argument, and it is worth knowing which one you are having before the letter is written.
- Contestable on your documents
- No ground stated, an arithmetic error, or a ground the agreement does not support. Firm ground for a letter.
- Clinical grounds — to discuss
- Refused as not indicated or not matching the diagnosis. Your documents do not settle these and neither does Mimi; take them to chat.
- Procedural — preventable, not recoverable
- Refused for want of authorization, and the claim carries no code. Arguing this rarely works; catching it before the patient is seen always does.
Reconciliation findings
Every deduction, with the ground the HMO gave and whether your documents support it. Clinical grounds are quantified, not argued — take those to chat.
₦3,330.00 deducted on clinical grounds — "NO INDICATION"
₦3,330.00 at riskKULUWA AL-MUSTAPHA · LAB · 04 Dec 2025 · row 7
The HMO reduced this line from ₦39,405.00 to ₦36,075.00, citing "NO INDICATION". That is a clinical-necessity ground. Nothing in the agreement, the tariff or the plan settles it, so the app records the amount and the stated ground but forms no view on the medicine. Take it to chat to work through whether it is worth contesting.
- Cites: HMO vetting response — comment: "NO INDICATION"
This turns on clinical necessity, which your documents do not settle. Ask about it in chat below — answers there point to a clinical source you can attach to a letter.
₦42,000.00 deducted for authorization — "NO AUTHORIZATION"
₦42,000.00 at riskKULUWA AL-MUSTAPHA · CONSULT · 09 Dec 2025 · row 9
The HMO cites "NO AUTHORIZATION", and the claim carries no Pre-Authorization code (the field reads "NIL"). On the record as it stands the deduction is consistent with the claim, and ₦42,000.00 is lost unless a code was in fact obtained and not captured.
- Cites: HMO vetting response — comment: "NO AUTHORIZATION"
What do you think?Hide
Opinion — not from your documents
Worth checking the front desk log before conceding — codes are often obtained by phone and never written onto the bill. If none exists, this line is better treated as a process failure to fix than a deduction to contest.₦93,240.00 deducted for authorization — "NO AUTHORIZATION"
₦93,240.00 at riskKULUWA AL-MUSTAPHA · LAB · 09 Dec 2025 · row 10
The HMO cites "NO AUTHORIZATION", and the claim carries no Pre-Authorization code (the field reads "NIL"). On the record as it stands the deduction is consistent with the claim, and ₦93,240.00 is lost unless a code was in fact obtained and not captured.
- Cites: HMO vetting response — comment: "NO AUTHORIZATION"
What do you think?Hide
Opinion — not from your documents
Worth checking the front desk log before conceding — codes are often obtained by phone and never written onto the bill. If none exists, this line is better treated as a process failure to fix than a deduction to contest.₦2,925.00 deducted on clinical grounds — "DOES NOT TALLY WITH DIAGNOSIS"
₦2,925.00 at riskSULAIMAN NASIR · LAB · 04 Dec 2025 · row 15
The HMO reduced this line from ₦24,732.48 to ₦21,807.48, citing "DOES NOT TALLY WITH DIAGNOSIS". That is a clinical-necessity ground. Nothing in the agreement, the tariff or the plan settles it, so the app records the amount and the stated ground but forms no view on the medicine. Take it to chat to work through whether it is worth contesting.
- Cites: HMO vetting response — comment: "DOES NOT TALLY WITH DIAGNOSIS"
This turns on clinical necessity, which your documents do not settle. Ask about it in chat below — answers there point to a clinical source you can attach to a letter.
No benefit table for the plan "GOLD FAMILY CAT. 2B (NR)"
₦174,645.00 at risk3 lines worth ₦174,645.00 sit on this plan, but its benefit table has not been added — so the app cannot say whether any of those services are covered for these enrollees. The tariff gives a price but carries no plan dimension: price and coverage are different questions, and only the benefit table answers the second.
- Cites: Venus Medicare Limited — plan setup
What do you think?Hide
Opinion — not from your documents
Coverage disputes are usually settled by quoting the plan's own benefit table back to the HMO. Getting that document on file is normally quicker than arguing a denial after the fact, and it is the same document their vetting officer will be reading.The plan "VML EXCLUSIVE FAMILY" is not set up for Venus Medicare Limited
₦24,732.48 at risk1 line worth ₦24,732.48 name the plan "VML EXCLUSIVE FAMILY", which does not exist under Venus Medicare Limited in the app. Either the plan is missing from setup, or the name on the bill differs from what the HMO calls it. Both are worth resolving before the claim goes out.
- Cites: Venus Medicare Limited — plan setup
Remittance matches the approved total
"2026-03-18-vml-payment-advice.pdf" remits ₦137,922.80, which agrees to the kobo with the ₦137,922.80 approved on the vetting sheet. Whatever is disputed on this batch, it is not the arithmetic between their two documents.
- Cites: 2026-03-18-vml-payment-advice.pdf — ₦137,922.80 (01 Mar 2026)
Documents
Any format. A returned sheet carrying approved amounts is recognised as the HMO's reply and switches this to a reconciliation.
2026-03-18-vml-payment-advice.pdf
Payment advice · 392.6 KB · dated 01 Mar 2026 (month named in the document: "March,2026" — day assumed to be the 1st)
Claim schedule
8 lines as parsed from your documents. Diagnosis is carried because the claim needs it; no finding reasons from it.
| Patient | Plan | Date | PA | Service | Billed | Approved | HMO comment | Flags |
|---|---|---|---|---|---|---|---|---|
| KULUWA AL-MUSTAPHAVML/FCTIRS/18332 | GOLD FAMILY CAT. 2B (NR) | 04 Dec 2025 | NIL | CONSULT | ₦22,200.00 | ₦22,200.00 | OK | — |
| KULUWA AL-MUSTAPHAVML/FCTIRS/18332 | GOLD FAMILY CAT. 2B (NR) | 04 Dec 2025 | NIL | DRUGS | ₦13,440.32 | ₦13,440.32 | OK | — |
| KULUWA AL-MUSTAPHAVML/FCTIRS/18332 | GOLD FAMILY CAT. 2B (NR) | 04 Dec 2025 | NIL | LAB | ₦39,405.00 | ₦36,075.00 | NO INDICATION | 1 |
| KULUWA AL-MUSTAPHAVML/FCTIRS/18332 | GOLD FAMILY CAT. 2B (NR) | 04 Dec 2025 | NIL | TOTAL | ₦75,045.32 | ₦71,715.32 | — | — |
| KULUWA AL-MUSTAPHAVML/FCTIRS/18332 | GOLD FAMILY CAT. 2B (NR) | 09 Dec 2025 | NIL | CONSULT | ₦42,000.00 | ₦0.00 | NO AUTHORIZATION | 1 |
| KULUWA AL-MUSTAPHAVML/FCTIRS/18332 | GOLD FAMILY CAT. 2B (NR) | 09 Dec 2025 | NIL | LAB | ₦93,240.00 | ₦0.00 | NO AUTHORIZATION | 1 |
| KULUWA AL-MUSTAPHAVML/FCTIRS/18332 | GOLD FAMILY CAT. 2B (NR) | 09 Dec 2025 | NIL | TOTAL | ₦135,240.00 | ₦0.00 | — | — |
| SULAIMAN NASIRVML/NDIC - SERVING STAFF/32863/1 | VML EXCLUSIVE FAMILY | 03 Dec 2025 | NIL | CONSULT | ₦22,200.00 | ₦22,200.00 | OK | — |
| SULAIMAN NASIRVML/NDIC - SERVING STAFF/32863/1 | VML EXCLUSIVE FAMILY | 03 Dec 2025 | NIL | TOTAL | ₦22,200.00 | ₦22,200.00 | — | — |
| SULAIMAN NASIRVML/NDIC - SERVING STAFF/32863/1 | VML EXCLUSIVE FAMILY | 04 Dec 2025 | NIL | CONSULT | ₦22,200.00 | ₦22,200.00 | OK | — |
| SULAIMAN NASIRVML/NDIC - SERVING STAFF/32863/1 | VML EXCLUSIVE FAMILY | 04 Dec 2025 | NIL | LAB | ₦24,732.48 | ₦21,807.48 | DOES NOT TALLY WITH DIAGNOSIS | 1 |
| SULAIMAN NASIRVML/NDIC - SERVING STAFF/32863/1 | VML EXCLUSIVE FAMILY | 04 Dec 2025 | NIL | TOTAL | ₦46,932.48 | ₦44,007.48 | — | — |
| VETTED AND CAPTURED BY:LASISI TOSIN AJIBOYE | VML EXCLUSIVE FAMILY | 04 Dec 2025 | NIL | TOTAL | ₦0.00 | — | — | — |
CONSULT
₦22,200.00KULUWA AL-MUSTAPHA · GOLD FAMILY CAT. 2B (NR) · 04 Dec 2025
PA: NILapproved ₦22,200.00HMO: “OK”
DRUGS
₦13,440.32KULUWA AL-MUSTAPHA · GOLD FAMILY CAT. 2B (NR) · 04 Dec 2025
PA: NILapproved ₦13,440.32HMO: “OK”
LAB
₦39,405.00KULUWA AL-MUSTAPHA · GOLD FAMILY CAT. 2B (NR) · 04 Dec 2025
PA: NILapproved ₦36,075.001 findingHMO: “NO INDICATION”
TOTAL
₦75,045.32KULUWA AL-MUSTAPHA · GOLD FAMILY CAT. 2B (NR) · 04 Dec 2025
PA: NILapproved ₦71,715.32CONSULT
₦42,000.00KULUWA AL-MUSTAPHA · GOLD FAMILY CAT. 2B (NR) · 09 Dec 2025
PA: NILapproved ₦0.001 findingHMO: “NO AUTHORIZATION”
LAB
₦93,240.00KULUWA AL-MUSTAPHA · GOLD FAMILY CAT. 2B (NR) · 09 Dec 2025
PA: NILapproved ₦0.001 findingHMO: “NO AUTHORIZATION”
TOTAL
₦135,240.00KULUWA AL-MUSTAPHA · GOLD FAMILY CAT. 2B (NR) · 09 Dec 2025
PA: NILapproved ₦0.00CONSULT
₦22,200.00SULAIMAN NASIR · VML EXCLUSIVE FAMILY · 03 Dec 2025
PA: NILapproved ₦22,200.00HMO: “OK”
TOTAL
₦22,200.00SULAIMAN NASIR · VML EXCLUSIVE FAMILY · 03 Dec 2025
PA: NILapproved ₦22,200.00CONSULT
₦22,200.00SULAIMAN NASIR · VML EXCLUSIVE FAMILY · 04 Dec 2025
PA: NILapproved ₦22,200.00HMO: “OK”
LAB
₦24,732.48SULAIMAN NASIR · VML EXCLUSIVE FAMILY · 04 Dec 2025
PA: NILapproved ₦21,807.481 findingHMO: “DOES NOT TALLY WITH DIAGNOSIS”
TOTAL
₦46,932.48SULAIMAN NASIR · VML EXCLUSIVE FAMILY · 04 Dec 2025
PA: NILapproved ₦44,007.48TOTAL
₦0.00VETTED AND CAPTURED BY: · VML EXCLUSIVE FAMILY · 04 Dec 2025
PA: NIL
Ask about this analysis
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