NHI Billing Services

Secure Eligibility Verification Submission

login

Fill out the form to create a new eligibility verification for processing.

NOTE: Eligibility Verifications may be submitted 24/7 through this website. If an EV is received outside regularly scheduled hours, our NHI staff will respond promptly during the next business day.
***For NHI contracted client use only***

Hospital Information

Facility Name required
the value is invalid
Contact Name required
the value is invalid
Contact Phone required
the value is invalid
Contact Email
the value is invalid
Contact Department
the value is invalid

Patient Information

LAST Name required
the value is invalid
FIRST Name required
the value is invalid
Patient Medicaid State required
the value is invalid
Medicaid ID
the value is invalid
Medicaid Card on File required
the value is invalid
Birthdate required
the value is invalid
Gender required
the value is invalid
Social Security Number
the value is invalid
Account Number / FIN required
the value is invalid

Visit Information

Visit Type required
the value is invalid
Mental Health Diagnosis required
the value is invalid
Service Start Date required
the value is invalid
Service End Date
the value is invalid
Diagnosis / Reason for Visit required
the value is invalid

Additional Information

Comments
the value is invalid
Notify By required
the value is invalid