New Claim

You are creating a new claim. Required fields are minimal so you can generate quickly.

Claim Header

Date of Service

Patient

Payer

Billing Provider

Rendering Provider

Total Charge

$0.00

Claim Line Items

Procedure Code	Diagnosis	Units	Charge / Unit	POS	Mod 1	Mod 2

Mark this claim as Submitted

If unchecked, the claim will be saved as Ready to Submit.

Eligibility hold placed for this claim

Use this to indicate that eligibility has been checked and a hold is in place in the eligibility app.

Eligibility Reference ID

Optional Attachment (PDF or Image)

If uploaded, this file will be stored with the claim and indicated in My Claims.