Line Items Section
- Enter the date of service, CPT/HCPCS code, place of service, up to four applicable modifiers, and a description of the service (if necessary).
- Identify the diagnosis based on the position in which the ICD-10 code was entered in the "Diagnosis Information"section (above).
- Enter the number of units.
- Enter the charge for the service.
- When "Organization" is selected at the top of the claim, identify the provider who rendered the service.
- If the service was ordered, identify the name and NPI of the ordering physician/practitioner.
- Select the purchased service indicator and other fields if applicable.
- Enter line items one at a time. After completing all applicable fields, click the "Add Line Information" button.
- Verify that all the lines added are correct.
- Select "Edit" to make changes to a claim line. The form will re-populate with claim line information, allowing you to make changes.
- Select "Delete" to remove a claim line.
- Enter the "Patient Amount Paid" ONLY when the patient paid for the service prior to submitting the claim.
- Enter the name of the person authorized to submit the claim on behalf of the provider. This will serve as an electronic signature.
NOTE: The "Total Charges" field is auto-populated based on the claim line charges added to the form.