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Claim Page 04 — Entering a RAP or Claim

Claim Page 04 (Map 1714) contains space for remarks.

screenshot example


  • RED = Required field
  • BLUE = Optional field
  • GREEN = Conditional field, depended on the type of claim
  • PURPLE = System generated field
  • BLACK = Not required field

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Field Descriptions for Claim Page 04 – Map 1714

The MID, TOB, S/LOC, and PROVIDER fields are system generated from information on Claim Page 01.

Field Name/Requirement



Key any additional pertinent information to assist the processing of the claim. Include the date of the remark and your initials.

Three pages are available to make remarks. Each page holds 10 lines of remarks. Press F6 to scroll forward to the next remark page.

Please note: CGS may also use this field to relay information back to the provider when the claim is in process or processed. Providers are encouraged to add remarks to MSP claims, claim adjustment and cancellations. Please be aware that remarks may be required on the claim, adjustment or cancellation.

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Additional FISS Claim Pages

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Updated: 10.02.18

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