Follow the steps to complete your claim form accurately

1. Press the ‘Get Form’ button to access the Iris Funded Non Hipaa Claims form and open it in your preferred editing tool.
2. Begin by entering the invoice number and associated Medicaid ID in the designated fields.
3. Fill out the invoice date, participant's first name, and date of birth. Ensure that all information matches the participant's records.
4. In the section for the provider, enter your name, provider ID, and contact information, including phone number and address (street, city, state, zip code).
5. Specify the billing period by entering the start and end dates. Ensure that these dates are in the CCYY-MM-DD format.
6. Complete the fields for service details, including procedure/revenue code, service from and to dates, modifiers, place of service, type of bill, unit type, rate, and billed amount.
7. Double-check all entries for accuracy, especially the total billed amount, which should reflect the cumulative charges for the services provided.
8. Obtain the signatures from the participant and the provider on the signature lines provided. Ensure that the date next to each signature is also filled in.
9. Once all sections are completed and reviewed, save the changes. You may now download, print, or share the filled form as needed.

Complete your Iris Funded Non Hipaa Claims form online today to ensure timely processing of your claims.