Print Open Negotiations Form

The Open Negotiations Form allows users to print an Open Negotiation Form (OMB 1210-0136) directly from the claim screen so that providers who are out-of-network can enter open negotiations with the insurance company to determine the amount that the insurance company will pay for emergency services.

  1. Select Claim > Claim.

  2. Use the Search field to search for your claim.  

    Place a check in the “Show exact matches only” box to search for exact matches or “Show unpaid claims only” to show claims that may need follow-up.

  1. Open the claim.

  2. Click the Print button.

  3. Select Open Negotiations Form.

  4. Enter the Signer's relationship to Insurance.

  5. Enter the out-of-network rate offer to the desired percentage of the total amount and click Set.

  6. Optional: You can also Enter/Edit the Offer for Total Out-of-Network Rate column for each individual service line.

  7. Click

  8. Click Save. Otherwise, click Close