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.
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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