{% extends "base.html" %} {% load static %} {% block title %}Claim {{ object.claim_number }} - {{ block.super }}{% endblock %} {% block content %}

Insurance Claim {{ object.claim_number }}

Back to List {% if object.status == 'DRAFT' %} Edit Claim {% endif %}
{% if object.status == 'DENIED' %}
Claim Denied
This claim has been denied by the insurance company. {% if object.denial_reason %}
Reason: {{ object.denial_reason }} {% endif %}
Appeal Resubmit
{% elif object.status == 'DRAFT' %}
Draft Claim
This claim is still in draft status. Review and submit when ready.
Submit Claim
{% elif object.status == 'APPROVED' %}
Claim Approved
This claim has been approved for ${{ object.approved_amount|floatformat:2 }} on {{ object.approval_date|date:"M d, Y" }}.
{% elif object.status == 'PAID' %}
Claim Paid
This claim has been paid by the insurance company on {{ object.payment_date|date:"M d, Y" }}.
{% elif object.status == 'PENDING' and object.days_pending > 30 %}
Long Pending Claim
This claim has been pending for {{ object.days_pending }} days. Consider following up with the insurance company.
{% endif %}
Claim Information
Claim Number: {{ object.claim_number }}
Submission Date: {% if object.submission_date %} {{ object.submission_date|date:"M d, Y" }} {% else %} Not submitted {% endif %}
Status: {% if object.status == 'DRAFT' %} Draft {% elif object.status == 'SUBMITTED' %} Submitted {% elif object.status == 'PENDING' %} Pending {% elif object.status == 'APPROVED' %} Approved {% elif object.status == 'PARTIALLY_APPROVED' %} Partially Approved {% elif object.status == 'DENIED' %} Denied {% elif object.status == 'PAID' %} Paid {% elif object.status == 'APPEALED' %} Appealed {% endif %}
Days Pending: {% if object.submission_date %} {{ object.days_pending }} days {% else %} - {% endif %}
Billed Amount: ${{ object.billed_amount|floatformat:2 }}
Approved Amount: {% if object.approved_amount %} ${{ object.approved_amount|floatformat:2 }} {% else %} - {% endif %}
Paid Amount: {% if object.paid_amount %} ${{ object.paid_amount|floatformat:2 }} {% else %} - {% endif %}
Created: {{ object.created_at|date:"M d, Y g:i A" }}
{% if object.notes %}
Notes:

{{ object.notes }}

{% endif %}
Related Bill
Bill Number: {{ object.medical_bill.bill_number }}
Bill Date: {{ object.medical_bill.bill_date|date:"M d, Y" }}
Service Date: {{ object.service_date|date:"M d, Y" }}
Total Amount: ${{ object.medical_bill.total_amount|floatformat:2 }}
Bill Status: {% if object.medical_bill.status == 'DRAFT' %} Draft {% elif object.medical_bill.status == 'PENDING' %} Pending {% elif object.medical_bill.status == 'SUBMITTED' %} Submitted {% elif object.medical_bill.status == 'PARTIAL_PAID' %} Partially Paid {% elif object.medical_bill.status == 'PAID' %} Paid {% elif object.medical_bill.status == 'OVERDUE' %} Overdue {% elif object.medical_bill.status == 'COLLECTIONS' %} Collections {% elif object.medical_bill.status == 'WRITTEN_OFF' %} Written Off {% elif object.medical_bill.status == 'CANCELLED' %} Cancelled {% endif %}
Provider: {{ object.medical_bill.billing_provider|default:"-" }}
Patient Information
Patient Name: {{ object.medical_bill.patient.get_full_name }}
MRN: {{ object.medical_bill.patient.mrn }}
Date of Birth: {{ object.medical_bill.patient.date_of_birth|date:"M d, Y" }}
Gender: {{ object.medical_bill.patient.get_gender_display|default:"-" }}
Phone: {{ object.medical_bill.patient.phone_number|default:"-" }}
Email: {{ object.medical_bill.patient.email|default:"-" }}
Address: {% if object.medical_bill.patient.address %} {{ object.medical_bill.patient.address }}
{{ object.medical_bill.patient.city }}, {{ object.medical_bill.patient.state }} {{ object.medical_bill.patient.zip_code }} {% else %} - {% endif %}
Insurance Information
Insurance Company: {{ object.insurance_info.insurance_company }}
Policy Number: {{ object.insurance_info.policy_number }}
Group Number: {{ object.insurance_info.group_number|default:"-" }}
Member ID: {{ object.insurance_info.member_id|default:"-" }}
Plan Type: {{ object.insurance_info.plan_type|default:"-" }}
Effective Date: {{ object.insurance_info.effective_date|date:"M d, Y"|default:"-" }}
Expiration Date: {{ object.insurance_info.expiration_date|date:"M d, Y"|default:"-" }}
Copay: {% if object.insurance_info.copay_amount %} ${{ object.insurance_info.copay_amount|floatformat:2 }} {% else %} - {% endif %}
Claim Line Items
{% for line_item in object.claimlineitem_set.all %} {% empty %} {% endfor %}
Service Code Description Service Date Quantity Billed Amount Approved Amount Status
{{ line_item.service_code }} {{ line_item.description }} {{ line_item.service_date|date:"M d, Y" }} {{ line_item.quantity }} ${{ line_item.billed_amount|floatformat:2 }} {% if line_item.approved_amount %} ${{ line_item.approved_amount|floatformat:2 }} {% else %} - {% endif %} {% if line_item.status == 'PENDING' %} Pending {% elif line_item.status == 'APPROVED' %} Approved {% elif line_item.status == 'DENIED' %} Denied {% elif line_item.status == 'PARTIALLY_APPROVED' %} Partially Approved {% endif %}
No line items found for this claim.
Claim Summary
Billed Amount: ${{ object.billed_amount|floatformat:2 }}
Approved Amount: {% if object.approved_amount %} ${{ object.approved_amount|floatformat:2 }} {% else %} - {% endif %}
Paid Amount: {% if object.paid_amount %} ${{ object.paid_amount|floatformat:2 }} {% else %} - {% endif %}
Outstanding: ${{ object.outstanding_amount|floatformat:2 }}
Quick Actions
{% if object.status == 'DRAFT' %} Submit Claim Edit Claim {% elif object.status == 'DENIED' %} Appeal Claim Resubmit Claim {% elif object.status in 'SUBMITTED,PENDING' %} Check Status {% endif %} Print Claim Download PDF View Bill
Claim Timeline
Claim Created

{{ object.created_at|date:"M d, Y g:i A" }}

{% if object.submission_date %}
Claim Submitted

{{ object.submission_date|date:"M d, Y g:i A" }}

{% endif %} {% if object.status == 'APPROVED' %}
Claim Approved

${{ object.approved_amount|floatformat:2 }} approved
{{ object.approval_date|date:"M d, Y g:i A"|default:"Unknown" }}

{% elif object.status == 'DENIED' %}
Claim Denied

{% if object.denial_reason %} {{ object.denial_reason }}
{{ object.denial_date|date:"M d, Y g:i A"|default:"Unknown" }} {% else %} {{ object.denial_date|date:"M d, Y g:i A"|default:"Unknown" }} {% endif %}

{% elif object.status == 'PARTIALLY_APPROVED' %}
Partially Approved

${{ object.approved_amount|floatformat:2 }} of ${{ object.billed_amount|floatformat:2 }}
{{ object.approval_date|date:"M d, Y g:i A"|default:"Unknown" }}

{% endif %} {% if object.status == 'PAID' %}
Payment Received

${{ object.paid_amount|floatformat:2 }} received
{{ object.payment_date|date:"M d, Y g:i A"|default:"Unknown" }}

{% endif %} {% if object.status == 'APPEALED' %}
Claim Appealed

{{ object.appeal_date|date:"M d, Y g:i A"|default:"Unknown" }}

{% endif %}
{% endblock %}