Supporting info and links
Documents the payer may ask for. Optional.
When the document was created
Choose a file
PDF, JPG or PNG, up to 10 MB each, 5 files at most. Provide either a file or a URL, not both.
Choose fileAccident details
Optional. Complete it if the request relates to an accident.Related claims
| Claim Reference | Relationship Type | Reference Identifier (Optional) | Status |
|---|---|---|---|
| Claim_9e61b4d7 | Associated Claim | Approved | |
| Claim_5b2c7e10 | Prior Claim | Expired |
Link this request to prior authorizations or previous claims. Format: Claim_[response id], a claim that NPHIES accepted (a rejected one cannot be linked). Relationship types: Prior Claim, Associated Claim, Authorization to Extend, Appealing.