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Step 4 - Claim lines

Suggest edit Updated on August 31, 2021

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/SectionFieldDefinition
Claim lines - Add claim lineDate 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 lineDate 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 qualifierDescribes the type of service units billed. Choose from the dropdown. Displayed when entering professional, institutional, or dental claims.
Claim lines - Add claim lineBilled amount*The charge amount for the service line. Displayed when entering professional, institutional, or dental claims.
Claim lines - Add claim lineProcedure 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 linePlace of serviceThe 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 modifierSelecting 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 numberSelecting 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.

Claim type(s)Provider type
Professional, InstitutionalReferring
Professional, Institutional, DentalRendering
Professional, DentalService facility
Professional, DentalSupervising
ProfessionalPurchased service
ProfessionalOrdering
InstitutionalOperating
InstitutionalOther operating
DentalAssistant surgeon

Displayed when entering professional, institutional, or dental claims.

The following fields are available in the claim lines step for professional claims only:

Step/SectionFieldDefinition
Claim lines - Add claim lineNational drug codeEnter or select the national drug code (NDC).
Claim lines - Add claim line+ Add diagnosis codeSelecting 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/SectionFieldDefinition
Claim lines - Add claim line – Tooth information+ Add tooth informationSelecting the link allows you to add one or more tooth codes to the claim line.
Claim lines - Add claim line – Tooth information+ Add tooth surfaceAllows you to associate a tooth surface with each tooth code.
Claim lines - Add claim line – Tooth information+ Add oral cavity designation codeSelecting 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 INFORMATIONProsthesis, crown, or inlay codeUsed 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 INFORMATIONReplacement dateIndicates 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 INFORMATIONTreatment start dateIndicates 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 INFORMATIONTreatment completion dateIndicates 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 INFORMATIONOrthodontic banding dateIndicates 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 INFORMATIONAdj repriced line ref numberEnter the adjusted repriced line reference number to identify a repriced/adjusted service line.
Claim lines - Add claim line – AUTHORIZATION INFORMATION+ Add predetermination of benefitsAllows 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/SectionFieldDefinition
Claim lines – Add claim line - SERVICEService fromThe 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 - SERVICEService toThe 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 - SERVICEService unit*The number of service units being billed.
Claim lines – Add claim line - SERVICENon covered chargesNon covered charges for the service line.
Claim lines – Add claim line - SERVICERevenue code*The revenue code describing the service being billed.
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