Step 3 - Claim header
This step lets you add the claim header information.
Pega Marketing User Guide
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 header | Transaction type | Indicates the type of claim transaction you are entering - New, Adjustment or Void/Cancel. Choose from the dropdown list. Displayed when entering professional or dental claims. |
| Claim header | Media type | Indicates the media type of the claim submission. Choose from the dropdown list. Displayed when entering professional, institutional, or dental claims. |
| Claim header | Claim identifier | Indicates whether the submission should be considered a Chargeable, Reporting, or Subrogation claim. Choose from the dropdown list. Displayed when entering professional, institutional, or dental claims. |
| Claim header | Diagnosis type* (required for professional and institutional claims; optional for dental claims) | Select ICD 9 or ICD 10 from the dropdown list to indicate which diagnosis type will be entered. Displayed when entering professional, institutional, or dental claims. |
| Claim header | Claim ID (ICN) | Allows you to enter the claim internal control number (ICN). Alternately, you can click Generate and SCE will generate and display a unique ICN. Displayed when entering professional, institutional, or dental claims. |
| Claim header | Submitted date* | Indicates the date the claim was submitted. Use the date picker or enter a date in this format: MM/DD/YYYY. Displayed when entering professional, institutional, or dental claims. |
| Claim header | Place of service | Indicates where the services were provided. Choose from the dropdown list. Displayed when entering professional or dental claims. |
| Claim header | Principal diagnosis* (required for professional and institutional claims; required for dental claims if a selection was made in the Diagnosis type field) | The diagnosis most responsible for the services being billed. |
| Claim header – ACCIDENT INFO | Accident type | Choose a checkbox to indicate an auto accident, an employment-related accident, or an accident type of other accident. Displayed when entering professional or dental claims. |
| Claim header – ACCIDENT INFO | Accident country | Choose the country where the accident occurred. Required if Accident type is Auto. Displayed when entering professional or dental claims. |
| Claim header – ACCIDENT INFO | Accident state | Choose the state where the accident occurred. Required if Accident type is Auto. Displayed when entering professional or dental claims. |
| Claim header – ACCIDENT INFO | Accident date | Indicates the date the accident occurred. Use the date picker or enter a date in this format: MM/DD/YYYY. Available when Accident type is Auto, Employment or Other accident. Displayed when entering professional or dental claims. |
| Claim header | Other insurance indicator | Choose Y (Yes), N (No), or W (Not applicable/Patient refuses) from the dropdown list. Displayed when entering professional or dental claims. |
| Claim header | Prior authorization number | The authorization number for the service. Displayed when entering professional, institutional, or dental claims. |
| Claim header | Claim referral number | The referral number for the service. Displayed when entering professional, institutional, or dental claims. |
The following fields are available in the claim header step for dental claims only:
| Step/Section | Field | Definition |
| Claim header | Date of service from | Use the date picker or enter a date in this format: MM/DD/YYYY to enter the beginning date of service for the claim. |
| Claim header | Date of service to | Use the date picker or enter a date in this format: MM/DD/YYYY to enter the final date of service for the claim. |
| Claim header | Number of enclosures | Enter the number of enclosures. |
| Claim header | Predetermination of benefits (checkbox) | Choosing the checkbox indicates the claim is being submitted for predetermination of benefits only. |
| Claim header | Predetermination of benefits identifier | If a predetermination of benefits was submitted prior to the services being submitted, this field is for entry of the predetermination of benefits claim ID. |
| Claim header | Treatment for orthodontics (checkbox) | Choosing the checkbox indicates the claim is being submitted for orthodontic services. |
| Claim header | Appliance placed date | Use the date picker or enter a date in this format: MM/DD/YYYY to enter the date the appliance was initially placed. |
| Claim header | Months of treatment | Enter the total number of months required to complete the orthodontic treatment. |
| Claim header | Months of treatment remaining | Enter the total number of months remaining to complete the orthodontic treatment. |
| Claim header | Replacement of prosthesis | Choose from the dropdown if applicable. |
| Claim header | Tooth information | Use the tooth chart to select the tooth numbers for missing teeth or to indicate teeth that will be extracted. |
The following fields are available in the claim header step for institutional claims only:
| Step/Section | Field | Definition |
| Claim header | Type of bill* | The type of bill submitted for the claim. The selection will auto populate the claim type (inpatient or outpatient) and claim submission type (new, void/cancel, or adjustment/replacement) fields. |
| Claim header | Patient status code* | Choose the patient status code from the dropdown. |
| Claim header | Statement covers from* | Use the date picker or enter a date in this format: MM/DD/YYYY to enter the statement covers from date. |
| Claim header | Statement covers to* | Use the date picker or enter a date in this format: MM/DD/YYYY to enter the statement covers to date. |
| Claim header | Admission date | Use the date picker or enter a date in this format: MM/DD/YYYY to enter the admission date. |
| Claim header | Admission hour | Use the time picker to select the admission hour. |
| Claim header | Discharge hour | Use the time picker to select the discharge hour. |
| Claim header | Type of admission | Choose the type of admission from the dropdown. |
| Claim header | Source of admission* | Select the source of admission. |
| Claim header – OTHER INFO | Medical record number | Enter the patient’s medical record number. |
| Claim header – OTHER INFO | PPS/DRG code | Enter a PPS or DRG code. |
| Claim header – OTHER INFO | PPS code type | Enter a PPS or DRG code type. Choose from the dropdown. |
| Claim header – DIAGNOSIS INFO | Present on admission | Select a choice from the dropdown. |
| Claim header – Diagnosis codes | + Add diagnosis code | Selecting the link opens a modal allowing you to add an admission diagnosis code, as well as providing a way to enter one or more other diagnosis codes and to select the associated Present on admission code from a dropdown list; you can also enter one or more external cause of injury codes and select the associated Present on admission code from a dropdown list. |
| Claim header – Occurrence codes | + Add occurrence code | Selecting the link opens a modal allowing you to add one or more condition codes, one or more occurrence codes and the associated date, and one or more occurrence span codes along with the From and To dates. |
| Claim header – Procedure and visit codes | + Add procedure and visit codes | Selecting the link opens a modal allowing you to add one or more reason for visit codes, a principal procedure code and the associated date of service, as well as one or more other procedure codes and the associated date of service. |
| Claim header – Value codes | Add value codes | Selecting the link opens a modal allowing you to add one or more value codes and the associated amount. |
Previous topic Step 2 - Providers Next topic Step 4 - Claim lines