Claim Detail

Member Information

Name: {{detailClaim.memberInfo.memberName.firstName}} {{detailClaim.memberInfo.memberName.lastName}}

Status: {{detailClaim.claimStatus.codeDesc}}

Other Insurance Paid: $ {{cobAmount}}

Relationship: {{detailClaim.memberInfo.memberRelationship.codeDesc}}

Date Processed:

Total Patient Responsibility: $ {{total}}

Dentist: {{detailClaim.providerInfo.providerName.firstName}} {{detailClaim.providerInfo.providerName.lastName}}

Check Number:

Date Received: {{detailClaim.dateReceived | date : "MM/dd/yyyy"}}

Check Issue Date:

{{detailClaim.claimPayment.checkIssueDate | date : "MM/dd/yyyy"}}

Claim ID: {{detailClaim.claimId}}

Claim Detail

Date of Service	Procedure Code	Procedure Code Description	Tooth Number	Charge	Allowed	Deductible	Benefit Amount
{{item.fromDate \| date : "MM/dd/yyyy"}}	{{item.procedureCode.codeValue}}	{{item.procedureCode.codeDesc \| uppercase}}	{{item.toothNumber}}	$ {{item.chargeAmount}}	$ {{item.allowedAmount}}	$ {{item.deductibleAmount}}	$ {{item.paidAmount}}
{{claimdetailerror }}