Programming
M150HIM1507 Rasmussen College Completing Private Payer Claims Assignment

M150HIM1507

Rasmussen College

Question Description

The objective of these exercises is to correctly complete private payer claims, applying what you have learned in the module.

In order to complete the claims you will need the following:

  1. Case Information which includes the Provider Information, Patient Information, and the Encounter Information.
  2. Fillable CMS-1500 Claim Form
    • Download this fillable CMS-1500 form and use it for filling in and saving a claim form for each case.
    • You can fill in this version of the form electronically, using Adobe Form Filler, as long as you have Adobe Acrobat Reader. (If you need the latest version of the free reader, you can download it from via the internet.) Note: Do not try to complete the form within your browser. First, save the file to your computer. Once you have completed the form, be sure to select "save as" from the File menu and re-name the file per the instructions below.

Unformatted Attachment Preview

Case 8.4a Based on the following Provider, Patient, and Encounter Information, complete a claim for the patient. Assume that the patient's relationship to the insured is "Self." Provider Information Name: Address: Telephone: Employer ID Number: NPI: Assignment: Signature: David Rosenberg, MD. 1400 West Center Street Toledo, OH 43601-0213 555-967-0303 16-2345678 1288560027 Accepts On File (1-1-2016) Patient Information Name Sex David Belline M Birth Date 1/22/1957 Marital Status Married SSN 439-01-3349 Address Employer 250 Milltown Rd. Alliance, OH 44601-3456 Kinko's Health Plan Anthem BCBS PPO Insurance ID Number 35Z29005 Assignment of Benefits Y Signature on File Y (06/01/2016) Condition unrelated to Employment, Auto Accident, or Other Accident Copayment $20 Encounter Information (found on the next page) Case 8.4a Encounter Information CARRIER HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12 PICA MEDICAID TRICARE CHAMPVA (Medicaid#) (ID#/DoD#) (Member ID#) GROUP HEALTH PLAN (ID#) FECA BLK LUNG (ID#) 3. PATIENT’S BIRTH DATE MM DD YY 2. PATIENT’S NAME (Last Name, First Name, Middle Initial) (ID#) 5. PATIENT’S ADDRESS (No., Street) F 6. PATIENT RELATIONSHIP TO INSURED Self CITY STATE ZIP CODE 4. INSURED’S NAME (Last Name, First Name, Middle Initial) SEX M Child Spouse 8. RESERVED FOR NUCC USE STATE CITY TELEPHONE (Include Area Code) ( 7. INSURED’S ADDRESS (No., Street) Other ZIP CODE TELEPHONE (Include Area Code) ( ) ) 9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH MM DD YY b. RESERVED FOR NUCC USE b. AUTO ACCIDENT? PLACE (State) c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME NO YES d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAIM CODES (Designated by NUCC) d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. SIGNED 15. OTHER DATE 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. QUAL. MM DD YY 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD YY FROM TO 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO 19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 20. OUTSIDE LAB? YES 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E) B. C. D. E. F. G. H. MM J. YY B. C. PLACE OF SERVICE EMG $ CHARGES NO 22. RESUBMISSION CODE ICD Ind. A. DATE(S) OF SERVICE From To DD YY MM DD If yes, complete items 9, 9a, and 9d. SIGNED 17b. NPI I. 24. A. NO 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. DATE 14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP) MM DD YY QUAL. F b. OTHER CLAIM ID (Designated by NUCC) NO YES c. RESERVED FOR NUCC USE SEX M NO YES ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER K. L. D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER E. DIAGNOSIS POINTER F. H. G. $ CHARGES I. J. RENDERING PROVIDER ID. # EPSDT ID. Family Plan QUAL. DAYS OR UNITS 1 NPI 2 NPI 3 NPI 4 NPI 5 NPI 6 NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? (For govt. claims, see back) YES 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) SIGNED DATE NO 32. SERVICE FACILITY LOCATION INFORMATION a. NUCC Instruction Manual available at: www.nucc.org NPI PATIENT AND INSURED INFORMATION MEDICARE (Medicare#) (For Program in Item 1) b. PLEASE PRINT OR TYPE 28. TOTAL CHARGE $ $ 33. BILLING PROVIDER INFO & PH # a. 30. Rsvd for NUCC Use 29. AMOUNT PAID NPI ( ) b. $33529('OMB)250  PHYSICIAN OR SUPPLIER INFORMATION 1. PICA OTHER 1a. INSURED’S I.D. NUMBER ...
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Final Answer

Attached.

CARRIER

HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
PICA
MEDICAID

TRICARE

CHAMPVA

(Medicaid#)

(ID#/DoD#)

(Member ID#)

GROUP
HEALTH PLAN
(ID#)

FECA
BLK LUNG
(ID#)

3. PATIENT’S BIRTH DATE
MM
DD
YY

2. PATIENT’S NAME (Last Name, First Name, Middle Initial)

(ID#)

5. PATIENT’S ADDRESS (No., Street)

F

6. PATIENT RELATIONSHIP TO INSURED
Self

CITY

STATE

ZIP CODE

4. INSURED’S NAME (Last Name, First Name, Middle Initial)

SEX
M

Child

Spouse

8. RESERVED FOR NUCC USE

STATE

CITY

TELEPHONE (Include Area Code)

(

7. INSURED’S ADDRESS (No., Street)

Other

ZIP CODE

TELEPHONE (Include Area Code)

(

)

)

9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)

10. IS PATIENT’S CONDITION RELATED TO:

11. INSURED’S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED’S POLICY OR GROUP NUMBER

a. EMPLOYMENT? (Current or Previous)

a. INSURED’S DATE OF BIRTH
MM
DD
YY

b. RESERVED FOR NUCC USE

b. AUTO ACCIDENT?

PLACE (State)

c. OTHER ACCIDENT?

c. INSURANCE PLAN NAME OR PROGRAM NAME
NO

YES
d. INSURANCE PLAN NAME OR PROGRAM NAME

10d. CLAIM CODES (Designated by NUCC)

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment
below.
SIGNED

15. OTHER DATE

17. NAME OF REFERRING PROVI...

glen34 (82)
New York University

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