Claim Detail
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PTE Detail
Claim Details
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PTE ID:{{detailClaim.claimId}} Claim ID:{{detailClaim.claimId}}
PTE Status:
{{detailClaim.claimStatus.codeDesc}}
Claim Status:
{{detailClaim.claimStatus.codeDesc}}
Date Processed:
{{detailClaim.dateProcessed | date : "MM/dd/yyyy"}}
Member Name:
{{detailClaim.memberInfo.memberName.firstName}} {{detailClaim.memberInfo.memberName.lastName}}
Relationship:
{{detailClaim.memberInfo.memberRelationship.codeDesc}}
Dentist:
{{detailClaim.providerInfo.providerName.firstName}} {{detailClaim.providerInfo.providerName.lastName}}
Date Received:
{{detailClaim.dateReceived | date : "MM/dd/yyyy"}}
Other Insurance Paid:
$ {{cobAmount}}
Total Patient Responsibility:
$ {{total}}
Please Note
You can submit multiple procedure codes in a PTE as a Claim in a single session. You cannot save your work and come back later. Once the Claim is submitted, you will not be able to return to the PTE to select additional procedure codes.
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Disclaimer
This Preauthorization of allowances is not a guarantee of payment and is subject to the following conditions:
1. Allowances may be reduced by entitlement to other insurance benefits.
2. Total benefits maximums may not exceed the plan maximums. Actual dates of service may alter the deductible application and benefits payable.
3. Allowances indicated below may vary if plan benefits change prior to performance of these services.
4. The patient must be eligible for benefits when the services are deemed incurred. An expense is incurred when a service is performed.
5. If your dentist or health care professional no longer participates in our network at the time services are rendered, the allowances indicated below may vary. Be sure to check your provider’s network status prior to your appointment for services.
Note to dentist: Please enter dates of services for all procedures completed, making any necessary corrections, additions or deletions to describe the work performed. Please refer to the Explanation of Benefits (EOB) to see how long this Preauthorization is valid.
1. Allowances may be reduced by entitlement to other insurance benefits.
2. Total benefits maximums may not exceed the plan maximums. Actual dates of service may alter the deductible application and benefits payable.
3. Allowances indicated below may vary if plan benefits change prior to performance of these services.
4. The patient must be eligible for benefits when the services are deemed incurred. An expense is incurred when a service is performed.
5. If your dentist or health care professional no longer participates in our network at the time services are rendered, the allowances indicated below may vary. Be sure to check your provider’s network status prior to your appointment for services.
Note to dentist: Please enter dates of services for all procedures completed, making any necessary corrections, additions or deletions to describe the work performed. Please refer to the Explanation of Benefits (EOB) to see how long this Preauthorization is valid.