Claim attachment

This form is limited to the online submission of attachments in support of a claim submitted through the electronic 837 format. All other correspondence will be disregarded.

The related electronic claim must have an attachment indicator and the attachment control number in the PWK segment of the 837 form.

Use our Quick Claim Submission Guide to review guidelines for common claim scenarios.

Provider information

*

Contact information

Claim information

Attachment information

The file/s have been attached and will be submitted with this form, but the attached file names are not available to display at this time.

You may continue and submit this form if you have attached the appropriate documentation, or click cancel to start over.

Attach the supporting documentation for services
{{attachment.controlId}} - {{attachment.filename}}

Less than one Megabyte attached (Maximum 20MB) {{totalAttachLength | number:2}} Megabytes attached (Maximum 20MB)
  • bmp (Bitmap-image file)
  • csv (Comma-delimited data/spreadsheet)
  • doc
  • docx
  • gif (Image file)
  • jpeg (Image file)
  • jpg (Image file)
  • odt (OpenDocument text file)
  • pdf
  • png (Image file)
  • psd (Photoshop image file)
  • rtf (Text file)
  • tif (Image file)
  • tiff (Image file)
  • txt
  • xls
  • xlsx
  • xml (Data file)
  • xps