Step 4 - Claim lines
This step lets you add one or more claim lines.
To add providers, click Add new; the Add claim line modal opens. Complete the modal using the information below.
Note: Fields are dynamically displayed based on claim type you are entering; the table below lists all possible fields for all claim types.
| Step/Section | Field | Definition | ||||||||||||||||||||
| Claim lines - Add claim line | Date of service from* (required for professional claims) | The beginning date of service for the claim line. Use the date picker or enter a date in this format: MM/DD/YYYY. Displayed when entering professional or dental claims. | ||||||||||||||||||||
| Claim lines - Add claim line | Date of service to* (required for professional claims) | The final date of service for the claim line. Use the date picker or enter a date in this format: MM/DD/YYYY. Displayed when entering professional or dental claims. | ||||||||||||||||||||
| Claim lines - Add claim line | Units* (required for professional claims) | The number of service units being billed. Displayed when entering professional or dental claims. | ||||||||||||||||||||
| Claim lines - Add claim line | Unit qualifier | Describes the type of service units billed. Choose from the dropdown. Displayed when entering professional, institutional, or dental claims. | ||||||||||||||||||||
| Claim lines - Add claim line | Billed amount* | The charge amount for the service line. Displayed when entering professional, institutional, or dental claims. | ||||||||||||||||||||
| Claim lines - Add claim line | Procedure code* (required for professional and dental claims) | The procedure code describing the service being billed. Displayed when entering professional, institutional, or dental claims. | ||||||||||||||||||||
| Claim lines - Add claim line | Place of service | The code indicating where the services were rendered. Choose from the dropdown. Displayed when entering professional or dental claims. | ||||||||||||||||||||
| Claim lines - Add claim line | + Add procedure code modifier | Selecting the link allows you to add one or more procedure code modifiers to the claim line. Displayed when entering professional, institutional, or dental claims. | ||||||||||||||||||||
| Claim lines - Add claim line | + Add prior authorization number | Selecting the link allows you to add one or more prior authorization numbers to the claim line. Displayed when entering professional or dental claims. | ||||||||||||||||||||
| Claim lines - Add claim line | + Add provider | Selecting the link allows you to add one or more providers to the claim line by selecting from the dropdown. The dropdown choices are as follows.
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Displayed when entering professional, institutional, or dental claims.
The following fields are available in the claim lines step for professional claims only:
| Step/Section | Field | Definition |
| Claim lines - Add claim line | National drug code | Enter or select the national drug code (NDC). |
| Claim lines - Add claim line | + Add diagnosis code | Selecting the link allows you to add additional diagnoses (other than the principal) to the claim line. |
The following fields are available in the claim lines step for dental claims only:
| Step/Section | Field | Definition |
| Claim lines - Add claim line – Tooth information | + Add tooth information | Selecting the link allows you to add one or more tooth codes to the claim line. |
| Claim lines - Add claim line – Tooth information | + Add tooth surface | Allows you to associate a tooth surface with each tooth code. |
| Claim lines - Add claim line – Tooth information | + Add oral cavity designation code | Selecting the link allows you to add one or more oral cavity designation codes to the claim line. Select from the dropdown. |
| Claim lines - Add claim line - ANCILLARY CLAIM/TREATMENT INFORMATION | Prosthesis, crown, or inlay code | Used when crowns and all fixed or removable prostheses are billed on the service line. Choose from the dropdown. |
| Claim lines - Add claim line - ANCILLARY CLAIM/TREATMENT INFORMATION | Replacement date | Indicates the prosthesis replacement date. Use the date picker or enter a date in this format: MM/DD/YYYY. |
| Claim lines - Add claim line - ANCILLARY CLAIM/TREATMENT INFORMATION | Treatment start date | Indicates the prosthesis or crown treatment start date. Use the date picker or enter a date in this format: MM/DD/YYYY. |
| Claim lines - Add claim line - ANCILLARY CLAIM/TREATMENT INFORMATION | Treatment completion date | Indicates the prosthesis or crown treatment completion date. Use the date picker or enter a date in this format: MM/DD/YYYY. |
| Claim lines - Add claim line - ANCILLARY CLAIM/TREATMENT INFORMATION | Orthodontic banding date | Indicates the orthodontic banding date. Use the date picker or enter a date in this format: MM/DD/YYYY. |
| Claim lines - Add claim line - ANCILLARY CLAIM/TREATMENT INFORMATION | Adj repriced line ref number | Enter the adjusted repriced line reference number to identify a repriced/adjusted service line. |
| Claim lines - Add claim line – AUTHORIZATION INFORMATION | + Add predetermination of benefits | Allows entry of one or more predetermination of benefits claim numbers for the service line. |
The following fields are available in the claim lines step for institutional claims only:
| Step/Section | Field | Definition |
| Claim lines – Add claim line - SERVICE | Service from | The beginning date of service for the claim line. Use the date picker or enter a date in this format: MM/DD/YYYY. |
| Claim lines – Add claim line - SERVICE | Service to | The final date of service for the claim line. Use the date picker or enter a date in this format: MM/DD/YYYY. |
| Claim lines – Add claim line - SERVICE | Service unit* | The number of service units being billed. |
| Claim lines – Add claim line - SERVICE | Non covered charges | Non covered charges for the service line. |
| Claim lines – Add claim line - SERVICE | Revenue code* | The revenue code describing the service being billed. |
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