Question

Provider Information

 

Billing Provider Valley Associates, PC NPI 1476543215

Address 1400 West Center Street, Toledo, OH 43601-0213

Telephone 555-967-0303

Employer ID Number 16-1234567

Rendering Provider Christopher M. Connolly, MD

NPI 8877365552

Oxford PPO Provider Number 1011

Oxford HMO Provider Number 2567

Assignment Accepts

Information About the Patient:

Name Kalpesh Shah

Sex M

Birth Date 01/21/2016

Marital Status Single

Address 1433 Third Avenue, Cleveland, OH 44101-1234

Telephone 555-608-9772

Employer Not Employed

Race White

Ethnicity Not Hispanic or Latino

Preferred Language English

 

Information About Insured:

Name Raj Shah

Patient Relationship to Insured Child

Sex M

Birthdate 02/16/1987

Marital Status Married

Address 1433 Third Avenue, Cleveland, OH 44101-1234

Telephone 555-608-9772

Employer Cleveland Savings Bank

Health Plan Oxford Freedom PPO

Insurance ID Number 3302112090X

Policy Number 0946582

Group Number G0904

Copayment/Deductible Amount $15 copay

Assignment of Benefits Y

Signature on File 01/01/2029

Condition Unrelated to Employment, Auto Accident, or Other Accident

A. Are the subscriber and the patient the same person?

B. What is the code for the patient’s relationship to the insured?

C. What is the claim filing indicator code?

D. What amount is being billed on the claim?

E. What claim control number would you assign to the claim?

Answer 1

A. No

B. 19

C. 12

D. $93

E. SHAHKAL0-10062016