Insurance Claim
Insurance claim documents are used by policyholders or healthcare providers to request reimbursement or payment from an insurer for healthcare services rendered, often including patient details, coverage information, and itemized charges.
Fields
| Field | Description | Example |
|---|---|---|
claim_id |
Unique identifier assigned to the insurance claim. | CLM-0012345 |
policy_number |
Insurance policy number under which the claim is filed. | POL-987654321 |
claimant_name |
Name of the person making the claim or the patient’s name. | John Doe |
provider_name |
Healthcare provider or facility that rendered services. | ABC Medical Clinic |
service_date_range |
Date(s) when medical services were performed. | 2023-06-01 to 2023-06-10 |
diagnosis_codes |
ICD or DSM codes describing the patient’s diagnosis. | J20.9, E11.9 |
procedure_codes |
CPT or HCPCS codes for services provided. | 99213, 81002 |
amount_billed |
Total amount billed for the services. | 500.00 |
amount_covered |
Portion of the amount that insurance covers. | 400.00 |
patient_responsibility |
Remaining amount the patient must pay out of pocket. | 100.00 |
claim_status |
Current status of the claim (e.g., pending, approved, denied). | Pending |
submission_date |
Date the claim was submitted to the insurer. | 2023-06-15 |