Claim Submission Form Template with Examples
What is a Claim Submission Form?
A claim submission form template is a standardized document used by healthcare providers to submit claims to insurance companies for reimbursement of services rendered. It documents all services provided, associated charges, and supporting clinical information required for insurance processing.
A well-structured claim submission form typically includes:
- Provider Information: Name, credentials, practice details, and tax ID
- Patient Information: Name, date of birth, policy number, and demographics
- Service Information: Dates of service, procedures performed, and procedure codes
- Charge Details: Itemized charges for each service with amounts
- Diagnosis Information: Primary and secondary diagnoses with ICD-10 codes
- Insurance Information: Insurance company name, policy number, and group number
- Authorization Information: Prior authorization numbers if applicable
- Supporting Documentation: Medical records, test results, and clinical evidence
Why Accurate Claim Submission is Essential
Accurate claim submission ensures timely reimbursement, prevents claim denials, supports compliance requirements, and enables effective revenue cycle management. Incomplete or inaccurate claims are delayed or denied, impacting cash flow.
Key Benefits:
- Reduces claim processing delays
- Accelerates reimbursement
- Prevents claim denials
- Improves first-pass acceptance rates
- Protects revenue
Key Components of a Claim Submission Form
1. Provider Information Section
- Provider name, credentials, and specialty
- Provider NPI number and tax ID
- Practice name, address, phone, and fax
2. Patient Information Section
- Patient full name, date of birth, patient ID
- Contact phone number and address
3. Insurance Information Section
- Insurance company name and address
- Policy number and group number
- Subscriber name and relationship to patient
4. Service Information Section
- Date of service, procedure code (CPT)
- Service description, quantity, charge amount
- Modifier codes (if applicable)
5. Diagnosis Information Section
- Primary diagnosis and ICD-10 code
- Secondary diagnoses and ICD-10 codes
- Diagnosis pointers (linking diagnoses to procedures)
6. Charge Details Section
- Service date, procedure code, description
- Charge amount, units/quantity, total charge
7. Authorization Information Section
- Prior authorization required (yes/no)
- Prior authorization number and date
- Authorization expiration date
8. Supporting Documentation Section
- Medical records attached
- Test results attached
- Imaging reports attached
- Clinical notes attached
Complete Claim Submission Form Template
CLAIM SUBMISSION FORM
PROVIDER INFORMATION:
Provider Name: _________________________________ Credentials: _______________
Specialty: _________________________ NPI: _________________________________
Practice Name: ________________________________________________________________
Address: ________________________________________________________________
Phone: _________________________ Fax: ___________________________________
Tax ID: _________________________ License #: _____________________________
PATIENT INFORMATION:
Patient Name: _________________________________ Date of Birth: ___/___/_____
Sex: ☐ Male ☐ Female ☐ Other
Address: ________________________________________________________________
Phone: _________________________ Email: __________________________________
Patient ID/MRN: _________________________
INSURANCE INFORMATION:
Insurance Company Name: ______________________________________________________
Policy Number: _________________________ Group Number: ___________________
Subscriber Name: _________________________ Relationship to Patient: _________
Subscriber DOB: ___/___/_____ Subscriber ID: ___________________________
SERVICE INFORMATION:
Date of Service | Procedure Code | Description | Qty | Charge Amount
_______________|________________|_____________|_____|_______________
___/___/_____ | ______________ | __________ | ___ | $____________
___/___/_____ | ______________ | __________ | ___ | $____________
___/___/_____ | ______________ | __________ | ___ | $____________
Total Charges: $______________
DIAGNOSIS INFORMATION:
Primary Diagnosis: _________________________ ICD-10 Code: ___________________
Secondary Diagnosis 1: _________________________ ICD-10 Code: ___________________
Secondary Diagnosis 2: _________________________ ICD-10 Code: ___________________
Diagnosis Pointers (link diagnoses to procedures):
Procedure 1: Diagnoses _______________________________________________________
Procedure 2: Diagnoses _______________________________________________________
MODIFIER INFORMATION (if applicable):
Procedure 1 Modifiers: _________________________
Procedure 2 Modifiers: _________________________
AUTHORIZATION INFORMATION:
Prior Authorization Required: ☐ Yes ☐ No
If yes, Authorization Number: _________________________ Date: ___/___/_____
Authorization Expiration Date: ___/___/_____
SUPPORTING DOCUMENTATION:
☐ Medical records attached
☐ Test results attached
☐ Imaging reports attached
☐ Clinical notes attached
☐ Pathology reports attached
☐ Other documentation: _____________________________________
CLAIM SUMMARY:
Total Charges: $______________
Less: Patient Responsibility: $______________
Amount Billed to Insurance: $______________
SUBMISSION INFORMATION:
Submission Method: ☐ Paper ☐ EDI ☐ Online ☐ Clearinghouse
Submission Date: ___/___/_____ Submission Time: _________
Submitted By: _________________________ Title: ____________________________
Confirmation #: _________________________ Reference #: __________________
CLAIM TRACKING:
Claim Status: ☐ Submitted ☐ Received ☐ Processing ☐ Approved ☐ Denied
Date Received by Insurance: ___/___/_____ Time: _________
Expected Processing Date: ___/___/_____
Insurance Contact Phone: _________________________ Reference #: __________
PROVIDER CERTIFICATION:
I certify that the information provided on this claim is accurate and complete.
I am submitting this claim for services rendered to the patient identified above.
Provider Signature: _________________________ Date: ___/___/_____
Provider Name (Print): _________________________ NPI: __________________________Automating Claim Submission with HealOS
Modern healthcare organizations are automating claim submission to submit claims accurately and efficiently, reducing denials and accelerating reimbursement.
1. Claim Processing Agent
Claim Processing Agent: Automatically creates, validates, and submits claims to insurance companies through multiple channels.
2. Claim Scrubber Agent
Claim Scrubber Agent: Validates claims in real-time to catch errors before submission, preventing denials.
3. Billing Management Agent
Billing Management Agent: Manages the complete billing workflow including charge posting, claim creation, and claim submission.
4. Clinical Documentation Agent
Clinical Documentation Agent: Ensures claim documentation includes all required clinical information and meets payer requirements.
5. AI Medical Scribe Agent
AI Medical Scribe Agent: Generates clinical documentation supporting claims, including diagnoses and medical necessity.
6. EHR Interoperability Agent
EHR Interoperability Agent: Automatically extracts relevant clinical information from the patient's EHR to support claims.
7. Denial Management Agent
Denial Management Agent: Manages claim denials and automates appeals with additional clinical documentation.
8. Accounts Receivable Management Agent
Accounts Receivable Management Agent: Tracks all submitted claims, monitors processing status, and follows up on delayed or denied claims.
9. Payment Integrity Agent
Payment Integrity Agent: Monitors insurance payments to ensure they are accurate and match the submitted claims.
10. Change Reconciliation Agent
Change Reconciliation Agent: Reconciles charges posted to patient accounts with claims submitted to insurance companies.
Automated Claim Submission Workflow
STEP 1: Service Documentation
├─ Provider documents service
├─ AI Medical Scribe Agent generates documentation
└─ Clinical Documentation Agent validates completeness
STEP 2: Claim Creation & Validation
├─ Claim Processing Agent creates claim
├─ Claim Scrubber Agent validates claim
├─ EHR Interoperability Agent extracts clinical data
└─ Billing Management Agent manages billing
STEP 3: Claim Submission
├─ Claim Processing Agent submits claim
├─ Change Reconciliation Agent reconciles charges
└─ Accounts Receivable Management Agent tracks claim
STEP 4: Status Monitoring & Follow-up
├─ Accounts Receivable Management Agent monitors status
├─ Alerts sent if delays occur
└─ Payment Integrity Agent monitors for payment
STEP 5: Payment & Reconciliation
├─ Insurance payment received
├─ Payment Integrity Agent validates payment
├─ Change Reconciliation Agent reconciles payment
└─ Denial Management Agent handles denials if needed
RESULT: Complete claim submission workflow automatedFAQs
Q: What information is required on a claim submission form?
Required information includes provider details, patient information, insurance information, service details (dates, codes, charges), diagnoses (ICD-10 codes), and supporting documentation.
Q: How long does claim processing take?
Most insurance companies process claims within 10-30 days. Electronic claims are typically processed faster than paper claims.
Q: What should I do if a claim is denied?
Review the denial reason, verify the information is accurate, and file an appeal if appropriate. The Denial Management Agent can automate this process.
Q: Should I submit claims electronically or on paper?
Electronic submission (EDI) is faster, more accurate, and more cost-effective than paper submission. Most insurance companies prefer electronic claims.
Q: How do I know if a claim was received by the insurance company?
Request a confirmation number when submitting the claim. The Claim Processing Agent provides confirmation numbers and tracks claim status automatically.
Q: What procedure codes should I use on a claim?
Use the CPT codes that accurately describe the services provided. The Claim Scrubber Agent validates codes for accuracy.
Q: How do I handle claims with multiple diagnoses?
Include all relevant diagnoses with their ICD-10 codes. Use diagnosis pointers to link diagnoses to specific procedures.
Q: What should I do if I submit a claim with incorrect information?
Contact the insurance company to request a correction or resubmit a corrected claim. The Denial Management Agent can help identify and correct claim errors.
Q: How do I track claim payments?
The Accounts Receivable Management Agent tracks all claims and payments automatically, providing status updates and alerts for delayed payments.
Q: What is a claim modifier and when should I use it?
Modifiers are two-digit codes that modify procedure codes to provide additional information. The Claim Scrubber Agent validates modifier usage.
Example Letter Template
