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Get Electronic Claim Attachment Control Number Form
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How to fill out the Electronic Claim Attachment Control Number Form online
The Electronic Claim Attachment Control Number Form is an essential document for processing electronic claims within the Nebraska Medicaid system. This guide provides clear, step-by-step instructions to assist users in accurately completing the form online.
Follow the steps to fill out the form correctly.
- Press the ‘Get Form’ button to access the Electronic Claim Attachment Control Number Form and open it in the designated editor.
- In the 'Attachment Control Number' field, input the unique claim attachment control number that corresponds to your electronic claim. Ensure this is the billing provider’s 10-digit NPI or the 11-digit Nebraska Medicaid legacy provider number, along with a unique number not exceeding 9-digits.
- Enter the name of the Nebraska Medicaid Billing Provider in the 'Provider Name' field.
- In the 'Billing Contact Name' field, provide the name of the person responsible for submitting claims for Medicaid payment.
- Fill in the 'Billing Contact Phone Number' field with the appropriate phone number for the billing contact.
- Input the full name of the individual who received the services in the 'Medicaid Client Name' section.
- Enter the complete 11-digit client identification number in the corresponding 'Medicaid Client Identification Number' field.
- For the 'Date(s) of Service', provide the 8-digit numeric service dates relevant to the attachment request.
- In the 'Type of Attachment' section, describe the type of attachment you are submitting alongside the form.
- Complete the final field by entering the total number of pages submitted, including the form itself.
- Once all fields are completed, save your changes. You can download, print, or share the form as necessary.
Ensure your electronic claims are processed efficiently by completing the necessary documents online.
An example of an attachment can include medical records, invoices, or any supporting documents relevant to a claim. These attachments provide essential information needed for processing your claim efficiently. Using the Electronic Claim Attachment Control Number Form allows you to submit these examples effectively and maintain clarity in your documentation.
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