Add

Delete

2000 loop

Click Add 2000 Loop link on right.

Entire 2000 loop structure appears after the current 2000 loops.

Fill out the fields and click Save at bottom left.

Delete all of its 2100 loops.

On its Claim Payment Information line, click Delete.

Under Form Actions at the bottom left, click Save.

2100 loop

To the right on the Claim Payment Information line, click Add 2100 Loop.

A new Claim Payment Information table appears with filled-out Header Information and then the empty structure for you to fill out.

When finished adding information, click the Save button above the Provider Adjustments – PLB section.

On its Claim Payment Information line, click Delete.

2110 loop

At the top of the Service Lines section, to the right, click Add 2110 Loop.

A new Service Line Information table appears with an empty structure for you to fill out.

When finished adding information, click the Save button after the CAS Segment section.

On its Service Line Information line, click Delete.

MIA and MOA segments

Fill out the information and click Save below the Service Line Information area.

Blank out its contents and click the Save button below the Service line section.

CAS segment

Expand the Service Line Information and click Add CAS Segment (Service Level Adj.)

Fill out the fields. Do not type dollar signs or commas.

Click the Save button below the Service Line section.

Blank out its contents and click the Save button below the Service line section.

PLB segment

Click Add PLB Segment at the bottom left, below the last Provider Adjustment – PLB.

You can click this multiple times to display multiple new PLBs.

Under Form Actions at the bottom left, click Save.

Click Delete to the right next to Date.