Generate and Submit 277 RFAI

Auto-fill RFAI using claim number or PDI.

Generate and Submit 277 RFAI

Manually enter claim data in the fields below.

Claim Information Manual Entry

Service Line Information

add new line

Claim {{ autoFormModel.claimId }} Information

Payer Name Payer ID Payer Claim Control Number Medical Record Number
{{prepopulatedInfo.payerName?prepopulatedInfo.payerName:'\u2013\u2013\u2013'}} {{prepopulatedInfo.payerId?prepopulatedInfo.payerId:'\u2013\u2013\u2013' }} {{prepopulatedInfo.payerClaimControlNumber?prepopulatedInfo.payerClaimControlNumber:'\u2013\u2013\u2013'}} {{prepopulatedInfo.medicalRecordNumber?prepopulatedInfo.medicalRecordNumber:'\u2013\u2013\u2013' }}
Billing Provider Billing Provider NPI Billing Provider TIN Bill Type
{{prepopulatedInfo.providerInformation?prepopulatedInfo.providerInformation: '\u2013\u2013\u2013'}} {{ prepopulatedInfo.providerNpi?prepopulatedInfo.providerNpi: '\u2013\u2013\u2013' }} {{ prepopulatedInfo.providerTin?prepopulatedInfo.providerTin: '\u2013\u2013\u2013' }} {{ prepopulatedInfo.billType?prepopulatedInfo.billType:'\u2013\u2013\u2013'}}
Patient Last Name Patient First Name Patient Identifier Patient Control Number
{{ prepopulatedInfo.patientLastname?prepopulatedInfo.patientLastname:'\u2013\u2013\u2013' }} {{ prepopulatedInfo.patientFirstName?prepopulatedInfo.patientFirstName:'\u2013\u2013\u2013' }} {{ prepopulatedInfo.patientIdentifier?prepopulatedInfo.patientIdentifier:'\u2013\u2013\u2013' }} {{ prepopulatedInfo.patientcontrolNumber?prepopulatedInfo.patientcontrolNumber:'\u2013\u2013\u2013'}}
Information Receiver Clearinghouse ID    
{{ prepopulatedInfo.informationReceiver?prepopulatedInfo.informationReceiver:'\u2013\u2013\u2013' }} {{ prepopulatedInfo.clearingHouseId?prepopulatedInfo.clearingHouseId:'\u2013\u2013\u2013'}}    
Service From Date Service To Date
{{ prepopulatedInfo.serviceFromDate }} {{ prepopulatedInfo.serviceToDate }}

Service Line Information

Service Line # Svc. From Svc. To Revenue Code Procedure Code Modifiers Charge Amount
{{line.serviceLineId}} {{line.serviceFrom}} {{line.serviceTo}} {{line.revenueCode}} {{line.procedureCode}} {{line.modifiers}} {{line.chargeAmount | currency:'USD':true:'1.2-2'}}

Error

This PDI/Claim ID has missing information.
A 277 Request cannot be submitted for this Claim/ PDI

This PDI/Claim ID currently has a pending 277 RFAI.
If you proceed, you will generate an additional request.
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