IMC XML Generator

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Provider Data

Service Type *

Claim Type *

Servicing Provider ID *

Facility ID *

Fund Name *

Fund Payee ID optional

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Invoice Number *

Account Paid *

Submission Authorised

IFC Indicator

Admission Date *

Discharge Date optional

Compensation Indicator optional

Accident Indicator

Assignment of Benefits *

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First Name *

Last Name *

Date of Birth *

Gender *

Medicare Number *

Medicare Sub-numerate *

Fund Membership ID *

UR Number optional

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Referral Provider Number *

Referral Date *

Period Type *

Referral Period required if Non-Standard

Override Type waives referral requirement

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