What to Submit?

Information Needed to Submit a Successful Electronic Claim:

 

  • Patient’s ID number (can be submitted with or without the suffix, example: 123456 or 123456 02
  • Patient’s date of birth
  • Patient’s first and last name
  • Patient’s address
  • If the patient is not the subscriber: Subscriber’s name, ID number, and date of birth  
  • Name, address, Tax ID, and National Provider Identifier (NPI) of the billing provider
  • Name and Tax ID of NPI of the:
    - Rendering provider
    - Attending physician
    - Referring physician ​​​
  • Date if service, or admit and discharge dates
  • Diagnosis codes (ICD-9, DRG)
  • Standard code sets (CPT-4, Revenue Code, CPCS, NDC) and description of procedure
  • Charge amount for each procedure
  • Place of service
  • Prior authorization number, if service required prior authorization