secureeclaims.com Open in urlscan Pro
23.253.193.245  Public Scan

Form analysis
3 forms found in the DOM

<form autocomplete="off" class="m-form m-form--label-align-left- m-form--state- ng-untouched ng-pristine ng-invalid" novalidate="">
  <div class="col-md-12">
    <div class="row">
      <div class="col-md-12 margin-top-15 margin-bottom-10">
        <div class="m-divider"><span></span><span><strong>Provider Information</strong></span><span></span></div>
      </div>
      <div class="form-group col-md-12"><label class="required-value" for="RequesterName">Requester Fullname</label>
        <div class="m-input-icon m-input-icon--left">
          <div class="m-input-icon m-input-icon--left"><input class="form-control m-input m-input--air ng-untouched ng-pristine ng-invalid" id="RequesterName" maxlength="256" name="RequesterName" required="" type="text"><span
              class="m-input-icon__icon m-input-icon__icon--left"><span><i class="la la-user"></i></span></span></div>
        </div><validation-messages><!----></validation-messages>
      </div>
      <div class="form-group col-md-12"><label class="required-value" for="providerNpi"> Provider NPI</label>(Please insert your NPI for search information) <div class="input-group ql-color-red"><input
            class="form-control m-input m-input--air width-percent-30 ng-untouched ng-pristine ng-invalid" id="providerNpi" name="providerNpi" required="" type="text" minlength="10" maxlength="10" pattern="^[0-9]*$"><input
            class="form-control m-input width-percent-70 ng-untouched ng-pristine" disabled="" name="providerName" readonly="" type="text"></div>
        <div><!----></div>
      </div>
      <div class="form-group col-md-6"><label class="required-value" for="EmailAddress">Email address</label>
        <div class="m-input-icon m-input-icon--left">
          <div class="m-input-icon m-input-icon--left"><input class="form-control m-input m-input--air ng-untouched ng-pristine ng-invalid" email="" id="EmailAddress" maxlength="256" name="EmailAddress" required="" type="email"><span
              class="m-input-icon__icon m-input-icon__icon--left"><span><i class="la la-at"></i></span></span></div>
        </div><validation-messages><!----></validation-messages>
      </div>
      <div class="form-group col-md-6"><label for="phone">Phone number</label>
        <div class="m-input-icon m-input-icon--left">
          <div class="m-input-icon m-input-icon--left"><p-inputmask class="customPhone form-control m-input m-input--air ui-inputwrapper-focus ng-untouched ng-pristine ng-valid" id="phone" mask="1 999-999-9999" name="phone"><input pinputtext=""
                type="text" name="phone" class="ui-inputtext ui-corner-all ui-state-default ui-widget"></p-inputmask><span class="m-input-icon__icon m-input-icon__icon--left"><span><i class="la la-phone"></i></span></span></div>
        </div>
      </div>
      <div class="col-md-12 margin-top-15 margin-bottom-10">
        <div class="m-divider margin-top-20"><span></span><span><strong>Patient Information</strong></span><span></span></div>
      </div>
      <div class="form-group col-md-4"><label class="required-value" for="firstName">First Name</label>
        <div class="m-input-icon m-input-icon--left"><input class="form-control m-input m-input--air ng-untouched ng-pristine ng-invalid" id="firstName" name="firstName" required="" type="text"><span
            class="m-input-icon__icon m-input-icon__icon--left"><span><i class="la la-user"></i></span></span></div>
      </div>
      <div class="form-group col-md-2"><label for="middleInitial">Middle Name</label>
        <div class="m-input-icon m-input-icon--left"><input class="form-control m-input m-input--air ng-untouched ng-pristine ng-valid" id="middleInitial" maxlength="1" minlength="0" name="middleInitial" type="text"><span
            class="m-input-icon__icon m-input-icon__icon--left"><span><i class="la la-user"></i></span></span></div>
      </div>
      <div class="form-group col-md-3"><label class="required-value" for="lastName">Last Name</label>
        <div class="m-input-icon m-input-icon--left"><input class="form-control m-input m-input--air ng-untouched ng-pristine ng-invalid" id="lastName" name="lastName" required="" type="text"><span
            class="m-input-icon__icon m-input-icon__icon--left"><span><i class="la la-user"></i></span></span></div>
      </div>
      <div class="form-group col-md-3"><label for="lastName">Maternal Surname</label>
        <div class="m-input-icon m-input-icon--left"><input class="form-control m-input m-input--air ng-untouched ng-pristine ng-invalid" id="maidenName" name="lastName" type="text"><span
            class="m-input-icon__icon m-input-icon__icon--left"><span><i class="la la-user"></i></span></span></div>
      </div>
      <div class="form-group col-md-4"><label class="required-value" for="Patients_DateOfBirth">Date of Birth</label>
        <div class="m-input-icon m-input-icon--left">
          <div class="m-input-icon m-input-icon--left"><input bsdatepicker="" class="form-control m-input m-input--air ng-untouched ng-pristine ng-valid" id="Patients_DateOfBirth" name="Patients_DateOfBirth" required=""><span
              class="m-input-icon__icon m-input-icon__icon--left"><span><i class="la la-calendar"></i></span></span></div>
        </div>
      </div>
      <div class="form-group col-md-4"><label class="required-value" for="contractNumber">Contract Number</label>
        <div class="m-input-icon m-input-icon--left"><input class="form-control m-input m-input--air ng-untouched ng-pristine ng-invalid" id="contractNumber" name="contractNumber" required="" type="text"><span
            class="m-input-icon__icon m-input-icon__icon--left"><span><i class="fa fa-barcode"></i></span></span></div>
      </div>
      <div class="form-group col-md-4"><label for="groupNumber">Group Number</label>
        <div class="m-input-icon m-input-icon--left"><input class="form-control m-input m-input--air ng-untouched ng-pristine ng-valid" id="groupNumber" maxlength="50" name="groupNumber" type="text"><span
            class="m-input-icon__icon m-input-icon__icon--left"><span><i class="la la-code"></i></span></span></div>
      </div>
      <div class="col-md-12 margin-top-15 margin-bottom-10">
        <div class="m-divider margin-top-20"><span></span><span><strong>Service Information</strong></span><span></span></div>
      </div>
      <div class="form-group col-md-3"><label class="required-value" for="Claim_SurgeryDate">Service Date </label>
        <div class="m-input-icon m-input-icon--left"><input bsdatepicker="" class="form-control m-input m-input--air bg-white ng-untouched ng-pristine ng-invalid" id="Claim_SurgeryDate" name="Claim_SurgeryDate" required=""
            placeholder="Service Date"><span class="m-input-icon__icon m-input-icon__icon--left"><span><i class="la la-calendar"></i></span></span><validation-messages><!----></validation-messages></div>
      </div>
      <div class="form-group col-md-7"><label class="required" for="hospitalNpi">Hospital NPI</label>
        <div class="input-group ql-color-red"><input class="form-control m-input m-input--air width-percent-30 ng-untouched ng-pristine ng-invalid" id="hospitalNpi" name="hospitalNpi" required="" type="text" minlength="10" maxlength="10"
            pattern="/^[0-9]{10}$/"><input class="form-control m-input width-percent-70 ng-untouched ng-pristine" disabled="" name="hospitalName" readonly="" type="text"></div>
        <div><!----></div>
      </div>
      <div class="form-group col-md-2">
        <div class="m--margin-top-35 m-radio-inline"><label class="m-radio m-radio--brand m-radio--check-bold"><input name="inpatient_group" required="" type="radio"
              class="ng-untouched ng-pristine ng-invalid"><span></span><strong>Inpatient</strong></label><label class="m-radio m-radio--brand m-radio--check-bold"><input name="inpatient_group" required="" type="radio"
              class="ng-untouched ng-pristine ng-invalid"><span></span><strong>Outpatient</strong></label></div>
      </div>
    </div>
  </div>
</form>

<form autocomplete="off" class="m-form m-form--label-align-left- m-form--state- ng-untouched ng-pristine ng-invalid" novalidate="">
  <div class="col-md-12">
    <div class="col-md-12 margin-top-15 margin-bottom-10">
      <div class="m-divider margin-top-20"><span></span><span><strong>Items</strong></span><span></span></div>
    </div>
    <div class="alert alert-warning col-md-12 text-center">Please add each implant (screws, plates, etc.) individually and specify the estimated quantity for that implant </div>
    <div class="m-demo">
      <div class="row">
        <div class="form-group col-lg-3"><label class="required-value">Procedure Type</label><p-dropdown id="procedureId" name="procedureId" optionlabel="name" styleclass="customDef" class="ng-tns-c0-0 ng-untouched ng-pristine ng-valid">
            <div class="ng-tns-c0-0 customDef ui-dropdown ui-widget ui-state-default ui-corner-all ui-helper-clearfix" style="width: 150px; height: 3.29rem;">
              <div class="ui-helper-hidden-accessible"><input class="ng-tns-c0-0" aria-haspopup="listbox" readonly="" type="text" aria-label=" "></div><!----><!----><label
                class="ng-tns-c0-0 ui-dropdown-label ui-inputtext ui-corner-all ui-placeholder ng-star-inserted">Select</label><!----><!---->
              <div class="ui-dropdown-trigger ui-state-default ui-corner-right"><span class="ui-dropdown-trigger-icon ui-clickable pi pi-chevron-down"></span></div><!---->
            </div>
          </p-dropdown></div>
        <div class="form-group col-lg-3"><label class="required-value">Category </label><p-dropdown id="categoryId" name="categoryId" optionlabel="name" styleclass="customDef" class="ng-tns-c0-1 ng-untouched ng-pristine ng-valid">
            <div class="ng-tns-c0-1 customDef ui-dropdown ui-widget ui-state-default ui-corner-all ui-helper-clearfix" style="width: 150px; height: 3.29rem;">
              <div class="ui-helper-hidden-accessible"><input class="ng-tns-c0-1" aria-haspopup="listbox" readonly="" type="text" aria-label=" "></div><!----><!----><label
                class="ng-tns-c0-1 ui-dropdown-label ui-inputtext ui-corner-all ui-placeholder ng-star-inserted">Select</label><!----><!---->
              <div class="ui-dropdown-trigger ui-state-default ui-corner-right"><span class="ui-dropdown-trigger-icon ui-clickable pi pi-chevron-down"></span></div><!---->
            </div>
          </p-dropdown></div>
        <div class="form-group col-lg-6"><label class="required-value" for="item">Item</label><p-dropdown id="item" name="item" optionlabel="name" required="" styleclass="customDef" class="ng-tns-c0-2 ng-untouched ng-pristine ng-valid">
            <div class="ng-tns-c0-2 customDef ui-dropdown ui-widget ui-state-default ui-corner-all ui-helper-clearfix ui-dropdown-clearable" style="width: 150px; height: 3.29rem;">
              <div class="ui-helper-hidden-accessible"><input class="ng-tns-c0-2" aria-haspopup="listbox" readonly="" type="text" aria-label=" "></div><!----><!----><label
                class="ng-tns-c0-2 ui-dropdown-label ui-inputtext ui-corner-all ui-placeholder ng-star-inserted">Select Item</label><!----><!----><i class="ui-dropdown-clear-icon pi pi-times ng-tns-c0-2 ng-star-inserted"></i>
              <div class="ui-dropdown-trigger ui-state-default ui-corner-right"><span class="ui-dropdown-trigger-icon ui-clickable pi pi-chevron-down"></span></div><!---->
            </div>
          </p-dropdown><validation-messages><!----></validation-messages></div>
      </div>
      <div class="row">
        <div class="form-group col-lg-2"><label class="required-value" for="cpt">CPT/HCPCS</label>
          <div class="input-group"><input class="form-control m-input m-input--air ng-untouched ng-pristine ng-invalid" id="cpt" name="cpt" required="" type="text"></div><validation-messages><!----></validation-messages>
        </div>
        <div class="form-group col-md-1"><label class="required-value">Qty.</label>
          <div class="input-group"><input class="form-control m-input m-input--air ng-untouched ng-pristine ng-invalid" id="quantity" min="1" name="quantity" required="" type="number"></div><validation-messages><!----></validation-messages>
        </div>
        <div class="form-group col-md-3"><label class="required-value">Requested Price</label>
          <div class="input-group"><input class="form-control m-input m-input--air ng-untouched ng-pristine ng-invalid" id="requestedPrice" min="1" name="requestedPrice" required="" type="number"></div>
          <validation-messages><!----></validation-messages>
        </div>
        <div class="form-group col-md-6 m--margin-top-25"><button class="btn btn-info m-btn pull-right" disabled=""><i class="fa fa-plus-circle"></i> Add </button></div>
      </div>
    </div>
  </div>
</form>

<form class="m-form m-form--label-align-left- m-form--state- ng-untouched ng-pristine ng-valid" novalidate="">
  <div class="col-lg-12">
    <div class="primeng-datatable-container"><p-table styleclass="table table-striped- table-bordered table-hover table-checkable dataTable no-footer">
        <div class="table table-striped- table-bordered table-hover table-checkable dataTable no-footer ui-table ui-widget ui-table-responsive"><!----><!----><!----><!----><!---->
          <div class="ui-table-wrapper ng-star-inserted">
            <table><!---->
              <thead class="ui-table-thead"><!---->
                <tr class="ng-star-inserted">
                  <th style="width: 10%;">CPT/HCPCS</th>
                  <th style="width: 67%;">Description</th>
                  <th style="width: 10%;">Qty.</th>
                  <th style="width: 10%;">Requested Price</th>
                  <th style="width: 3%;"></th>
                </tr>
              </thead><!---->
              <tfoot class="ui-table-tfoot ng-star-inserted"><!----><!----><!----></tfoot>
              <tbody class="ui-table-tbody"><!----><!----><!----><!----><!----><!----><!----><!----><!----></tbody>
            </table>
          </div><!----><!----><!----><!----><!----><!---->
        </div>
      </p-table><!---->
      <div class="primeng-no-data ng-star-inserted"> No data </div>
    </div>
    <div class="primeng-paging-container pull-right"><span class="total-records-count"> Total: 0 </span></div>
  </div>
  <div class="col-md-12 margin-top-15 margin-bottom-10">
    <div class="m-divider margin-top-20"><span></span><span><strong>Support Documents</strong></span><span></span></div>
  </div>
  <div class="centered-content">
    <div class="row">
      <div class="col-md-12">
        <div class="form-group m-form__group text-center"><label class="control-label highlight">Please attach invoice with detailed information about the implants being quoted and medical order.</label><p-fileupload accept="application/pdf"
            multiple="multiple" name="SupportDocuments"><!---->
            <div class="ui-fileupload ui-widget ng-star-inserted">
              <div class="ui-fileupload-buttonbar ui-widget-header ui-corner-top"><span class="ui-fileupload-choose ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-left" icon="pi pi-plus" pbutton=""><input type="file"
                    multiple="" accept="application/pdf"><span aria-hidden="true" class="ui-button-icon-left ui-clickable pi pi-plus"></span><span class="ui-button-text ui-clickable">Choose</span></span><!----><!----><!----></div>
              <div class="ui-fileupload-content ui-widget-content ui-corner-bottom"><!----><p-messages class="ng-tns-c2-3"><!----></p-messages><!----><!---->
                <div class="form-group m-form__group row height-percent-100 ng-star-inserted">
                  <div class="col-md-12 col-md-12 col-sm-12">
                    <div class="m-dropzone dropzone m-dropzone--success dz-clickable" id="m-dropzone-three"><!---->
                      <div class="m-dropzone__msg dz-message needsclick margin-top-em-1 ng-star-inserted">
                        <h3 class="m-dropzone__msg-title"> Drop files here or click to upload.</h3><span class="m-dropzone__msg-desc">Only support documents: *.xlsx, *.pdf files are allowed for upload</span>
                      </div><!---->
                    </div>
                  </div>
                </div>
              </div>
            </div><!---->
          </p-fileupload></div>
      </div>
    </div>
  </div>
</form>

Text Content

CREATE NEW QUOTE REQUEST

Set all information for create new quote request.

MMM - MMM ADVANTAGE


QUOTE REQUEST DATA INFORMATION


Provider Information
Requester Fullname

Provider NPI(Please insert your NPI for search information)


Email address

Phone number

Patient Information
First Name

Middle Name

Last Name

Maternal Surname

Date of Birth

Contract Number

Group Number

Service Information
Service Date

Hospital NPI


InpatientOutpatient
Items
Please add each implant (screws, plates, etc.) individually and specify the
estimated quantity for that implant
Procedure Type

Select

Category

Select

Item

Select Item

CPT/HCPCS

Qty.

Requested Price

Add

CPT/HCPCSDescriptionQty.Requested Price

No data
Total: 0
Support Documents
Please attach invoice with detailed information about the implants being quoted
and medical order.
Choose


DROP FILES HERE OR CLICK TO UPLOAD.

Only support documents: *.xlsx, *.pdf files are allowed for upload
Close
Quote Request Type:
Audit Agreement Letter
Expedite
Send Request