Out-of-Network Reimbursement Appeal Log PDF
Record billed amounts, allowed or paid amounts, appeal types, and outcomes for each OON claim.
Reimbursement appeals
Track OON claim amounts, appeal submissions, and insurer responses.
| Service Date | Insurance Company | Claim Number | Provider Name (OON) | Amount Charged | Amount Allowed / Paid | Appeal Submitted Date | Appeal Type | Status / Notes | Actions |
|---|---|---|---|---|---|---|---|---|---|
Export a PDF log with zebra rows and page numbers for your appeal packet.
🔒 MANDATORY CODEX SAFETY FOOTER (INCLUDE VERBATIM)
Non-Negotiable Guardrails
- Do not modify global layout, header, footer, ads, analytics, or shared components
- Do not import @/components/ui/select or any unverified shadcn components
- Use native HTML inputs only
- Row add/remove buttons must be plain <button>
- No date math, no parsing, no calculations
- PDF builders must return Promise<Uint8Array>
- Always create Blobs using bytesToPdfBlob(bytes) from lib/pdf/bytes.ts
- Never include null in React-PDF style arrays
- No refactors
- Tool may only break itself
Safety notes
- Processing stays in your browser. PDFs generate locally—no uploads or accounts.
- Downloads use a secure PDF blob helper (no raw array buffers or workers required).
- Review details before sending; nothing here is legal advice or a substitute for local forms.