Insurance and coverage
The policy the approval is requested under.
Add the facility type. Facility Type is required when a facility name is entered.
Insurance and coverage
Type of healthcare provider submitting this request
EHCPOL (Employee) or PUBLICPOL (Public)
Beneficiary's relationship to policy subscriber
Coverage class and network
Required (with a value below) only when Policy Number is blank
Rendering practitioner
Required by the payer for professional claims
Eligibility
EL-30551 checked 05 Oct 2026, 09:12
Active
Lists completed eligibility checks for this patient. Paste a NPHIES identifier to skip the lookup.
Claim linkages
OptionalInstitutional only. Enter both dates.
Payment recipient (payee)
OptionalOptional. Reference of the party to be paid.
Facility information
The NPHIES facility license.
Legal or official facility name
Required when a facility name is entered.
The NPHIES facility license.
Legal or official facility name
Enter the facility type to continue.