Medical Insurance Claim EDI Portal

Follow these 3-Steps to Ensure Your Insurance Claim Does Not Get Denied

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CALL your Insurance Provider and Ask the Following Questions!

  1. Ask if your policy coverage needs a “Prior Authorization” BEFORE a claim is submitted.
  2. The Medical Billing Code (CPT/HCPCS) for our wheelchair is K0813.
  3. Ask what their coverage amount will be according to your policy. Then you will know exactly how much you will need to pay out-of-pocket.
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GET A SCRIPT from your Medical Doctor. This script should have the following information:

  1. The Script should be written to cover a “Portable Electric Wheelchair“.
  2. Include all your Medical Diagnosis Codes (alphanumeric codes only).
  3. Include your Doctor’s Contact Information.
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FILL OUT the Insurance Claim Form below AFTER you have completed Steps 1 & 2!

  • We DO NOT hold partial claim information.
  • We DO NOT accept fax copies with your medical information.
  • Insurance companies process all claims electronically.
  • Your claim will NOT be submitted with partial information

MEDICAL INSURANCE CLAIMS TAKE 6 TO 8 MONTHS BEFORE YOU RECEIVE YOUR CHAIR

FILL OUT THE MEDICAL INSURANCE FORM ONLY AFTER YOU COMPLETE STEPS 1 & 2

FILL OUT THE MEDICAL INSURANCE FORM BELOW

INSURANCE Claim

Please complete the form below to assist us in submitting a claim to your insurance provider. It is our passion to do whatever we can to help our customers break free from their physical prisons, and find freedom, independence, and mobility.
  • Date Format: MM slash DD slash YYYY
  • (###) ###-####


  • Insurance Provider Information

  • Many insurance providers require prior authorization for a portable electric wheelchair. Call your provider to see if your policy requires prior authorization for billing code K0813.
  • Please upload an image of the FRONT of your medical insurance card.
    Drop files here or
    Accepted file types: jpg, gif, png, pdf, bmp, tiff, doc, docx, jpeg.
  • Please upload an image of the BACK of your medical insurance card.
    Drop files here or
    Accepted file types: jpg, gif, png, pdf, bmp, tiff, doc, docx, jpeg.

  • Referring Doctor's Information

  • List any and all alpha numeric diagnosis codes for your current disease, illness or injury. Keep in mind not all codes qualify for an electric wheelchair. CODE EXAMPLES: M19.90, S49.91, G89.29, etc.
  • Please upload an image of your doctor's script.
    Drop files here or
    Accepted file types: jpg, gif, png, pdf, bmp, tiff, doc, docx, jpeg.

  • Model of Your Wheelchair

  • If you have any unique instructions for us, please let us know.
  • FOLD & GO WHEELCHAIRS® does not inflate the purchase price of our wheelchairs when we submit a claim to your provider. The purchase of your wheelchair is clearly listed on our website for your insurance provider to validate.
  • FOLD & GO WHEELCHAIRS® does not have contracted discounted pricing with ANY insurance provider.
  • FOLD & GO WHEELCHAIRS® does not ship your wheelchair until we have received payment from your insurance provider, and any out-of-pocket portion you may owe.
  • FOLD & GO WHEELCHAIRS® does not allow any returns, refunds or exchanges for wheelchairs purchased by an Insurance Provider. Once your Insurance Provider pays for your chair, you cannot return it. Your Insurance Provider views this action as FRAUD.