PTE Detail
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PTE Detail
{{preloginError}}
Member Information
{{detailClaim.memberInfo.memberName.firstName}} {{detailClaim.memberInfo.memberName.lastName}}
{{detailClaim.claimStatus.codeDesc}}
$ {{cobAmount}}
{{detailClaim.memberInfo.memberRelationship.codeDesc}}
{{detailClaim.dateProcessed | date : "MM/dd/yyyy"}}
$ {{total}}
{{detailClaim.providerInfo.providerName.firstName}} {{detailClaim.providerInfo.providerName.lastName}}
{{detailClaim.claimPayment.checkNumber}}
{{detailClaim.dateReceived | date : "MM/dd/yyyy"}}
{{detailClaim.claimPayment.checkIssueDate | date : "MM/dd/yyyy"}}
{{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 }}