HS215 Final Project
Directions: Read each part of the assignment carefully and be sure to turn in all parts.
Part I: Encounter forms
Encounter forms are used to generate insurance claims. They have patient identification
information, the date of service, and abbreviated diagnosis and procedure codes. The provider
will check or circle the appropriate codes on the encounter form, and the insurance specialist
enters the data (office charge, amount paid by the patient, and the total due).
Review the encounter form for JOHN SMITH which is located in “DOC SHARING”. Answer the
following questions in a Word document:
1. During processing of the encounter form (to generate the claim), the billing specialist notices
that the provider entered a check mark in front of the procedure, “Hemoccult Stool,” and a check
mark in front of the diagnosis, “Gout.” Because medical necessity requires the diagnosis
selected to justify the procedure performed, what should the Billing specialist do next?
2. The provider will accept whatever the payer determines is the allowed fee as payment in full.
Should the provider enter a check mark in the YES box for “ACCEPT ASSIGNMENT” on the
CMS1500? What is the ITEM NUMBER(s) of the section of the CMS 1500 form that the patient
signs to authorize payment to the provider?
3. Refer to the CMS-1500 claim form (Figure 4-1) on page 62 in your text. Which block on this
form would contain an entry based on information contained in the encounter form section
“DATE SYMPTOMS APPEARED, INCEPTION OF PREGNANCY, OR ACCIDENT
Part II: Explanation of Benefits
The patient receives an explanation of benefits (EOB) when the claims adjudication process is
finalized. Payment will be either denied or approved. The EOB contains information about what
was paid by the insurance company and any amount that the patient is responsible for.
Although it is the patient’s responsibility to review the claim for errors, they often contact the
office for assistance if they do find any. It is very important that the billing is done properly to
avoid errors and non-payment.
Review the explanation of benefit forms for Mary Smith located in “DOC SHARING”.
In a Word document, answer the following:
1. What was the total amount that The Keystone Plan was charged for Mary S. Patient’s
services on 05/04/2010?
2. How much has Mary S. Patient paid out of pocket year to date? (Assume that the deductible
has been paid in full)
3. What is Mary S. Patient’s MEMBER ID number?
4. What was the total allowed amount by the insurance company for Mary S. Patient’s
services on 05/04/2010?W
5. What is Mary S. Patient’s annual medical/surgical deductible, according to the EOB?
HS215 Final Project
Part III: CMS-1500 claim forms
For this project, you will be completing two parts that will include two different claim forms. One
claim form will be a Medicare insurance primary payer CMS-1500 form and the other will be a
Medicaid insurance primary payer CMS-1500 claim form.
You may find it helpful to refer to the tutorial on the SIMClaim CMS-1500 Student Practice
CDROM that is in the plastic pocket on the inside back cover of your text. See page xxi in your
text for information on how to use the CD-ROM.
Part A: Medicare Primary Claim Form:
• You will be using a Blank CMS-1500 form.
• Save the form under a different file name before you start your work. Work from the
• Refer to Table 14-4, the CMS-1500 claims completion instructions for Medicare primary
in your text, on page 550 to assist you with this assignment.
• Use the ENCOUNTER FORM FOR MADELINESMITH, a married lady found in
“DOCSHARING” to complete this assignment.
• The procedure codes and diagnosis codes are notated on this document.
Part B: Medicaid Primary Claim Form
• Download the blank CMS-1500 form.
• Refer to the CMS-1500 Medicaid claims completion instructions (primary) in your text,
Table 15-1 on page 583 to assist you with the assignment.
• Utilize the Case Study 2-11 on Page 701 scroll down to second image of your text.
In block 21, enter these two diagnosis codes: 473.9, Chronic Sinusitis and 462,
The patient information appears on page 701 and the progress note for the visit
on page 600 (is the third image on the page).
The Procedure codes for this case are - 99212, Established patient, Level 2,
$75.00, and 87880, Strep Test, $30.00.
DO NOT USE THE PROCEDURES OR DIAGNOSIS IN THE BOOK (case study
Before you turn in your final project, check this list to make sure you have everything:
• Part I Questions
• Part II Questions
• Part A: Medicare Primary Claim Form
• Part B: Medicaid Primary Claim Form
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