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dental-insurance-claim.pdf
Viewer
JSON
claim_number
DEN-2024-234567
claim_date
2024-03-05
policy_number
DDP-2024-890123
group_number
DENTAL-2000
patient_name
David Thompson
patient_dob
1990-11-15
patient_member_id
DT901115
patient_address
567 Smile Lane, Seattle, WA 98101
subscriber_name
David Thompson
subscriber_relationship
Self
dentist_name
Dr. Sarah Kim, DDS
dentist_npi
9876543210
dentist_license
WA-12345
office_name
Seattle Family Dentistry
office_address
100 Dental Plaza, Seattle, WA 98102
date_of_service
2024-03-01
Procedures
3 items
ada_code
tooth
surface
description
fee
D0120
N/A
N/A
Periodic oral evaluation
65
D1110
N/A
N/A
Prophylaxis - adult
120
D0274
N/A
N/A
Bitewings - four films
75
total_fee
260
other_coverage
false
dental-insurance-claim.pdf
Viewer
JSON
claim_number
DEN-2024-234567
claim_date
2024-03-05
policy_number
DDP-2024-890123
group_number
DENTAL-2000
patient_name
David Thompson
patient_dob
1990-11-15
patient_member_id
DT901115
patient_address
567 Smile Lane, Seattle, WA 98101
subscriber_name
David Thompson
subscriber_relationship
Self
dentist_name
Dr. Sarah Kim, DDS
dentist_npi
9876543210
dentist_license
WA-12345
office_name
Seattle Family Dentistry
office_address
100 Dental Plaza, Seattle, WA 98102
date_of_service
2024-03-01
Procedures
3 items
ada_code
tooth
surface
description
fee
D0120
N/A
N/A
Periodic oral evaluation
65
D1110
N/A
N/A
Prophylaxis - adult
120
D0274
N/A
N/A
Bitewings - four films
75
total_fee
260
other_coverage
false
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DocuPipe captures dental insurance claims from dental offices, member portals, or email submissions. Extract procedure codes, tooth surfaces, and fee schedules, then route to claims systems for automated adjudication.
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