CLAIM PROCESSING RISK ANALYSIS INFORMATION GATHERING FORM

OnPulse Billing Assistants

We help provide clarity and confidence to insurance navigation so you can focus on the important things. 

Your benefit analysis will include the discovery of insurance details and a personalized report of potential claim success and reimbursement.

OnPulse Billing Assistant Services May Include:
Primary Contact information:

Patient Information:

Insurance Information


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I am interested in billing and claims services for the following facility (facilities):
*Please include Facility name and Dates of service* *
Diagnoses prompting admission or enrollment into the above facility (facilities):
Did the patient have a referring provider who recommended enrollment/admission as medically necessary? *

We may enhance our review accuracy and efficiency if you grant access to your insurance web portal. Your insurance web portal is the website in which you are able to view/access claims, fees and benefit information. If you'll provide your login details to temporarily allow us to review fully, you are then free to change the login access at any time.

I authorize and grant OnPulse access to my protected health information within my insurance specific web portal: *
Signature: *
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Our free consultation includes a review of your benefit coverage so that we may advise on the risks associated with claims processing and rejection. Variables include but are not limited to whether or not your carrier provides out of network coverage and your current standing with deductibles. Beyond that, additional variables include medical necessity and authorization. OnPulse does its best to safeaguard your investment into our services by ensuring we've analyzed risk and enabled you to make the most educated decision to move foward in claim submission and processing. Due to above variables, claim processing services and cumulative amounts are not guaranteed. 
Chat: www.onpulse.com     Email: Hello@Onpulse.com     Call: 919-321-0300