Claims Processing
Required Client Demographic Information
- Client LME Affiliation (Example: Foothills, Neuse, Wake, Etc.)
- Client LME Medical Record Number
- Client Provider Medical Record Number
- Client First, Middle, Maiden & Last Name
- Client Date of Birth
- Gender (Male/Female)
- Client Street Address
- Client City , State & Zip Code
- Client Diagnosis Information
- Primary Diagnosis 1
- Primary Diagnosis 2
- Primary Diagnosis 3
- Primary Diagnosis 4
- Start/End Date of Above Diagnosis
- Client Funding Sources
- Medicaid
- Medicare
- IPRS
- Primary Insurance
- Client Funding Source Information (Information required for each funding source)
- Client Eligibility Identification Number
- Funding Source Effective/Lapse Dates
- Funding Source Plan Name
(Examples: Medicaid, Medicare, Blue Cross, CIGNA, etc.)
- Funding Source Policy Holder Information
- First, Middle Initial & Last Name
- Street Address, City, State & Zip Code
- Telephone Number including Area Code
- Policyholder Relation to Client
- Policyholder Date of Birth
- Policyholder Gender
Required Staff/Attending Provider Information
- Staff/Attending Provider Status (Profit/Non-Profit)
- Staff/Attending Provider Last Name
- Staff/Attending Provider First Name
- Staff/Attending Provider Middle Name
- Staff/Attending Provider Maiden Name
- Staff/Attending Provider Credentials (if applicable)
- Staff/Attending Provider Location/Facility
- Staff/Attending Provider Location/Facility Street Address
- Staff/Attending Provider Location/Facility City, State & Zip Code
- Federal ID#
- Staff/Attending Provider Billing Number
- Staff/Attending Provider IPRS Enrollment Number
- Endorsed Provider (Yes/No)
- Provisional Endorsement (Yes/No)
- Endorsement Effective/Lapse Dates
- Endorsed Services