Question 1

What does the professional claim extractor pull from a CMS-1500?

Accepted Answer

The claim number and date, claim status, patient name, date of birth, member ID and gender, the billing provider name, NPI and tax ID, the payer name and ID, the service period, and the place of service, plus any prior authorization and referring provider NPI.

Question 2

Are the service lines itemized?

Accepted Answer

Yes. The service lines table returns one row per line with the procedure code, modifier, service date, quantity, charge amount, allowed amount, paid amount, patient responsibility, diagnosis pointer, and any denial code, so a multi-line claim comes back ready to reconcile.

Question 3

How are diagnoses and procedures captured?

Accepted Answer

ICD-10-CM diagnosis codes and CPT, HCPCS, or ICD-10-PCS procedure codes are read at the claim level, and the diagnoses table returns each diagnosis number, code, description, and a primary indicator.

Question 4

Which money fields come out?

Accepted Answer

Total charge amount, allowed amount, paid amount, and patient responsibility at the claim level, alongside the adjudication outcome, so a submitted claim or its remittance both map to the same figures.

Question 5

What happens to a claim containing PHI after processing?

Accepted Answer

It runs through the Talonic API for extraction only, is not retained for training, and is not shared. Redact identifiers where possible; for BAA-covered work, ask about the Talonic platform. PDF only, up to 10MB and 100 pages.

Professional Claim (CMS-1500) Extractor

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