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Step 3 - Claim header

Suggest edit Updated on August 31, 2021

This step lets you add the claim header information.

Note: Fields are dynamically displayed based on claim type you are entering; the table below lists all possible fields for all claim types.

Step/SectionFieldDefinition
Claim headerTransaction typeIndicates 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 headerMedia typeIndicates the media type of the claim submission. Choose from the dropdown list. Displayed when entering professional, institutional, or dental claims.
Claim headerClaim identifierIndicates 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 headerClaim 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 headerSubmitted 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 headerPlace of serviceIndicates 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 typeChoose 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 INFOAccident countryChoose the country where the accident occurred. Required if Accident type is Auto. Displayed when entering professional or dental claims.
Claim header – ACCIDENT INFOAccident stateChoose the state where the accident occurred. Required if Accident type is Auto. Displayed when entering professional or dental claims.
Claim header – ACCIDENT INFOAccident dateIndicates 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 headerOther insurance indicatorChoose Y (Yes), N (No), or W (Not applicable/Patient refuses) from the dropdown list. Displayed when entering professional or dental claims.
Claim headerPrior authorization numberThe authorization number for the service. Displayed when entering professional, institutional, or dental claims.
Claim headerClaim referral numberThe 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/SectionFieldDefinition
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 headerDate of service toUse the date picker or enter a date in this format: MM/DD/YYYY to enter the final date of service for the claim.
Claim headerNumber of enclosuresEnter the number of enclosures.
Claim headerPredetermination of benefits (checkbox)Choosing the checkbox indicates the claim is being submitted for predetermination of benefits only.
Claim headerPredetermination of benefits identifierIf 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 headerTreatment for orthodontics (checkbox)Choosing the checkbox indicates the claim is being submitted for orthodontic services.
Claim headerAppliance placed dateUse the date picker or enter a date in this format: MM/DD/YYYY to enter the date the appliance was initially placed.
Claim headerMonths of treatmentEnter the total number of months required to complete the orthodontic treatment.
Claim headerMonths of treatment remainingEnter the total number of months remaining to complete the orthodontic treatment.
Claim headerReplacement of prosthesisChoose from the dropdown if applicable.
Claim headerTooth informationUse 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/SectionFieldDefinition
Claim headerType 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 headerPatient status code*Choose the patient status code from the dropdown.
Claim headerStatement covers from*Use the date picker or enter a date in this format: MM/DD/YYYY to enter the statement covers from date.
Claim headerStatement covers to*Use the date picker or enter a date in this format: MM/DD/YYYY to enter the statement covers to date.
Claim headerAdmission dateUse the date picker or enter a date in this format: MM/DD/YYYY to enter the admission date.
Claim headerAdmission hourUse the time picker to select the admission hour.
Claim headerDischarge hourUse the time picker to select the discharge hour.
Claim headerType of admissionChoose the type of admission from the dropdown.
Claim headerSource of admission*Select the source of admission.
Claim header – OTHER INFOMedical record numberEnter the patient’s medical record number.
Claim header – OTHER INFOPPS/DRG codeEnter a PPS or DRG code.
Claim header – OTHER INFOPPS code typeEnter a PPS or DRG code type. Choose from the dropdown.
Claim header – DIAGNOSIS INFOPresent on admissionSelect a choice from the dropdown.
Claim header – Diagnosis codes+ Add diagnosis codeSelecting 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 codeSelecting 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 codesSelecting 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 codesAdd value codesSelecting the link opens a modal allowing you to add one or more value codes and the associated amount.
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