Use this feature to create claim requests with following steps.


Step 1: Navigate NPHIES -> Claims -> Create Claim

Create claim screen is further divided into following screens: -

  • Claim Information
  • Beneficiary 
  • Subscriber: Only appears, if patient is New Born
  • Care Team
  • Diagnosis
  • Vision Prescription: Only appears, if claim type is optical.
  • Supporting Info
  • Items 
  • Accident 
  • Encounter

Step 1: Navigate to NPHIES -> Claims -> Create Claim-> Claim Information. Fill claim information. Note: Fields with * are mandatory to be filled by provider.

Step 2: Navigate to NPHIES -> Claims -> Create Claim-> Beneficiary Information. Fill Beneficiary information. Fields with * are mandatory to be filled by provider. 

Note: If patient is New Born, keep New Born flag on. System will then show a separate of screen as “Subscriber” to provide subscriber details to the insurance company. To fill subscriber details, navigate to NPHIES -> Claims -> Create Claim-> Subscriber

Step 3: Navigate to NPHIES -> Claims -> Create Claim-> Care Team. Fill Care Team information. Fields with * are mandatory to be filled by provider. 


Note: In Pharmacy Claim Type provider can skip entering Care Team Details.


Step 4: Navigate to NPHIES -> Claims -> Create Claim-> Diagnosis. Fill Diagnosis details

Field with * are mandatory.

Step 5: Navigate to NPHIES -> Claims -> Create Claim->Supporting Info. 


Note: Supporting info is a useful section to provide information to explain the authorization request medical reasons. For example, chief complaint, attachment for invoice, Lab Test results etc. Supporting Info section is optional to provide, however, for medication service, “Days of Supply” must be provided and link to medication-code service. Secondly, for extending a referred patient authorization, “Reason for Visit = Referral” is mandatory. 


Note: Supporting Info section is optional to provide, however, for medication service, “Days of Supply” must be provided and link to medication-code service. Secondly, for extending a referred patient authorization, “Reason for Visit = Referral” is mandatory. Moreover, few of the supporting info category.


Step 6: Navigate to NPHIES -> Claims -> Create Claim-> Item. Enter Items Information (Field with * are mandatory). Use this section to add product or service information that need an authorization and corresponding pricing breakdown. Click on “+” sign to add the section. Note: Click on service item “+” Button to expand. All the added items in package will can be seen.

Step 7: Navigate to NPHIES -> Claims -> Create Claim-> Accident. Enter Accident details.

It is an optional section under which Healthcare provider need to enter details, if patient encountered any accident. 

Step 8: Navigate to NPHIES->Claims->Create Claims->Vision Prescription.

Note: This section is mandatory to be filled with Optical Claim type.

Step 9: Navigate to NPHIES->Claims->Create Claims->Encounter. Fill encounter details, it is an optional field.

Step 10: Once update all mandatory and required information for claim request, user need to make a click upon “Save” button at bottom right corner of the screen.


Note: Against every transaction system runs validation. If any validation error is noted then system will not allow user to save created claim. It will show missed parameters in red color. Once provider will enter correct information, they need to again make a click upon “Save” button. After successful claim creation, system will give message to the healthcare provider “ Successfully Saved”. Once user click upon “OK”, system will open claim transaction in editable mode. User can modify or update transaction accordingly, if required. User can check for such claims in Upload, under “Ready for Submission” Claim status.