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Document Type Detected
CMS 1500 — Professional Claim
Confidence
97%
Processing complete — 8 fields extracted
2.3s
Scanned Document
SCANNED DOCUMENT
CMS-1500 (02-12) Health Insurance Claim Form
1. MEDICARE☑
MEDICAID☐
TRICARE☐
CHAMPVA☐
OTHER☐
1a. Insured's ID NumberBCB-884721-A
Insurance TypeMedicare
Patient & Insured Information
2. Patient's NameJohnson, Sarah M
3. Patient's Birth Date03 / 15 / 1958
5. Patient's Address1822 Maple Ave, LA, CA
17b. NPI147_____8
Diagnosis / Nature of Illness or Injury
A. ICD CodeE11.65
B.
C.
D.
Services / Procedures
24A. Date of Service[empty]
24B. POS11
24D. Proc99213
24F. Charges$__4.00
Billing Provider Info
33. Billing ProviderValley Medical Group
33a. NPI2345678901
Extracted Fields
8 fields · 2 need review
✅
Patient Name 94%
Sarah Johnson
✅
Date of Birth 97%
03/15/1958
✅
Insurance ID 88%
BCB-884721-A
⚠️
Provider NPI 72% Review recommended
✅
Diagnosis Code 91%
E11.65 — Type 2 DM w/ hyperglycemia
❌
Service Date 65% Manual entry required
⚠️
Total Charges 88% Partial extraction
✅
Billing Provider 93%
Valley Medical Group
Extraction Summary
5
High Confidence
2
Needs Review
1
Manual Entry