SurveyJS in your appMIT

Claims

CMS-1500: scans into records with AI, and back onto the sheet as PDF.

3 claims

Claim #PatientStatusTotal chargeActions
CLM-2026-0001Ava Nguyenapproved$1,840.50
CLM-2026-0002Marcus Bellin review$320.00
CLM-2026-0003Priya Shahsubmitted$215.75

Add a new claim from a filled document (PDF or scan)

Pick a document below: the survey's own JSON tells the model which CMS-1500 box each answer comes from, and the claim arrives in the list as a draft, open beside it in the real inputs for you to check against the document.

Office visit and EKG

A PDF straight out of billing software: Margaret Chen, three service lines, $248.00 total.

Back pain and therapy

The same form off a scanner - skewed, tinted, grainy: Rosa Delgado, three service lines, $415.00 total. A scan has no text layer, so this one goes through the model's OCR: expect the odd digit to need a correction.

Or try it with a CMS-1500 of your own - a PDF, a scan or a photo.Supported formats: PDF, PNG, JPG, WEBP. Up to 8 MB.This is a demo, not a service. The file is sent to an LLM provider for this one reading and is not stored here, and the claim it produces lives in this demo's memory until the server restarts - so please upload sample or made-up forms, never real patient data.

View CLM-2026-0001

Customize Claim Form

Save as PDF prints this claim onto the CMS-1500 (02/12) sheet itself, box for box - the same form the answers are read from, not a picture of this questionnaire.

Health Insurance Claim (CMS-1500)
Create or edit a claim record, box by box as the paper form.
Record
Record
Internal to this app - not part of the paper form.
Claim number 
Status 
Insurance program
Program
Insured's ID number
Patient
Last name 
First name 
MI
Date of birth
Sex
Street address
City
State
ZIP
Phone
Relationship to insured
Insured and policy
Last name
First name
MI
Street address
City
State
ZIP
Phone
Policy group or FECA number
Date of birth
Sex
Other claim ID
Insurance plan or program name
Another health benefit plan?
Other insurance
A second policy that also covers the patient.
Other insured's name
Policy or group number
Insurance plan or program name
Is the condition related to
Employment (current or previous)
Auto accident
Other accident
Claim codes
Signatures
Patient's signature
Signed on
Insured's signature
Dates and referral
Current illness, injury or pregnancy began
Qualifier
Other date
Qualifier
Unable to work from
Unable to work to
Referring provider
Qualifier
Referring provider NPI
Hospitalized from
Hospitalized to
Diagnosis and authorization
Additional claim information
Outside lab?
ICD indicator
Diagnosis codes
Resubmission code
Original ref. no.
Prior authorization number
Services
Service lines
Billing
Federal tax ID
Tax ID type
Patient's account no.
Accept assignment?
Total charge
Amount paid
Provider signature
Signed on
Service facility
Address
City, state, ZIP
Facility NPI
Billing provider
Address
City, state, ZIP
Phone
Billing NPI