new.nmrportal.com
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104.210.13.175
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URL:
https://new.nmrportal.com//CaseTask/Browse/08da05835f21c0e3540475617de672dbe6e450b73a38fbbc97f20830543ba276
Submission: On October 07 via api from US — Scanned from DE
Submission: On October 07 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST /CaseTask/CaseMessageReply
<form action="/CaseTask/CaseMessageReply" method="post"><input id="Hash" name="Hash" type="hidden" value="08da05835f21c0e3540475617de672dbe6e450b73a38fbbc97f20830543ba276">
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<div class="dxflVATSys dxflGroupCell_Material">
<div class="dxflGroupBox_Material dxflGroupBoxSys">
<span class="dxflGroupBoxCaption_Material">Non-initiating party</span>
<div class="dxflGroup_Material dxflGroupSys dxflAGSys dxflElConSys dxflFloatedElConSys" data-groupid="group_0" style="padding-top:0px;">
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<label class="dxflCaption_Material" for="ClientName_I">Payor:</label>
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<td class="dxic" style="width:100%;"><input class="dxeEditArea_Material dxeEditAreaSys" id="ClientName_I" name="ClientName" readonly="readonly" onchange="ASPx.EValueChanged('ClientName')"
value="American Public Life Company" type="text" autocomplete="off"></td>
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<label class="dxflCaption_Material" for="ClientContactEmail_I">Contact Email:</label>
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<table class="dxeTextBoxSys dxeTextBox_Material dxeReadOnly_Material readonly dxeTextBoxDefaultWidthSys" id="ClientContactEmail" style="width:100%;">
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<td class="dxic" style="width:100%;"><input class="dxeEditArea_Material dxeEditAreaSys" id="ClientContactEmail_I" name="ClientContactEmail" readonly="readonly" onchange="ASPx.EValueChanged('ClientContactEmail')"
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<label class="dxflCaption_Material" for="ClientContactFirstName_I">Contact First Name:</label>
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<label class="dxflCaption_Material" for="ClientContactLastName_I">Contact Last Name:</label>
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<div class="dxflNestedControlCell_Material" style="width:100%;">
<table class="dxeTextBoxSys dxeTextBox_Material dxeReadOnly_Material readonly dxeTextBoxDefaultWidthSys" id="ClientContactLastName" style="width:100%;">
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<td class="dxic" style="width:100%;"><input class="dxeEditArea_Material dxeEditAreaSys" id="ClientContactLastName_I" name="ClientContactLastName" readonly="readonly" onchange="ASPx.EValueChanged('ClientContactLastName')"
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<label class="dxflCaption_Material" for="ClientContactTimeZoneName_I">Contact Time Zone:</label>
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<td class="dxic" style="width:100%;"><input class="dxeEditArea_Material dxeEditAreaSys" id="ClientContactTimeZoneName_I" name="ClientContactTimeZoneName" readonly="readonly"
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<label class="dxflCaption_Material" for="ClientContactCity_I">Contact City:</label>
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<div class="dxflNestedControlCell_Material" style="width:100%;">
<table class="dxeTextBoxSys dxeTextBox_Material dxeReadOnly_Material readonly dxeTextBoxDefaultWidthSys" id="ClientContactCity" style="width:100%;">
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<label class="dxflCaption_Material" for="ClientContactZipCode_I">Contact Zip Code:</label>
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<table class="dxeTextBoxSys dxeTextBox_Material dxeReadOnly_Material readonly dxeTextBoxDefaultWidthSys" id="ClientContactZipCode" style="width:100%;">
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<label class="dxflCaption_Material" for="ClientContactFax_I">Contact Fax:</label>
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<label class="dxflCaption_Material" for="ClientContactStateName_I">Contact State:</label>
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<div class="dxflVATSys dxflGroupCell_Material">
<div class="dxflGroupBox_Material dxflGroupBoxSys">
<span class="dxflGroupBoxCaption_Material">Dispute Communication</span>
<div class="dxflGroup_Material dxflGroupSys dxflAGSys dxflElConSys dxflFloatedElConSys" data-groupid="group_1" style="padding-top:0px;">
<div id="detailFormLayout_1_0" style="width: 100%; margin-left: 0%;" class="dxflNotFloatedElSys dxflChildInFirstRowSys dxflFirstChildInRowSys dxflLastChildInRowSys" data-left="40">
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autocomplete="off">Bundled arrangement, resubmit the entire claim as a single line item under a single service code.</textarea></td>
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<div class="dxflNestedControlCell_Material">
<span class="dxeBase_Material" id="LbDisputeCommunicationInformation" style="display:inline-block;height:25px;margin-top:5px;">Attached Documents:</span>
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<table>
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<td>
<a class="dxeHyperlink_Material" onclick="return ASPx.SEClick('HplDisputeCommunicationIDocument_497163', event)" id="HplDisputeCommunicationIDocument_497163" style="cursor:pointer;">Dispute not eligible for the Federal IDR Process [incorrectly batched]</a>
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</td>
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<div class="dxflHALSys dxflVATSys dxflCaptionCell_Material dxflCaptionCellSys" style="width: 159px; min-width: 159px;">
<label class="dxflCaption_Material" for="No_I">Case #:</label>
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