Submit New Claim

Create a new mental health insurance claim submission.

Provider Information

Enter details about the healthcare provider

Provider Type

Provider Name

NPI Number

License Number

Practice Name

Network Status

Patient Information

Enter details about the patient

Patient Name

Date of Birth

Insurance ID

Insurance Provider

Service Information

Enter details about the service provided

Service Type

Service Date

Total Charge ($)

Payment Collected ($)

CPT Code

Diagnosis Code

Service Description

Supporting Documents

Upload supporting documentation for your claim

You will be able to upload files after submitting the claim.