Question

Encounter Date: 05/04/2029
Patient: Elizabeth R. Sinowitcz
Date of Birth: 08/02/1954
Address: 45 Maple Hill Road, Apt. 12-B, Rangeley, MN 55555
Home Telephone: 555-123-9887
Employer: Argon Electric Company, 238 Industry Way, Rangeley, MN 55554
Work Telephone: 555-124-8754

Betty is on Medicare. She also has insurance coverage through Argon Electric in the Horizon PPO. Her insurance card shows her member number as 65-PO; no group number is shown.

Betty was referred to Dr. Hank R. Ferrara, a Horizon-participating ophthalmologist (PIN 349-00-G), for evaluation of her blurred and dimmed vision. After conducting an examination and taking the necessary history, Dr. Ferrara diagnoses the patient’s condition as a cortical age-related cataract of the left eye that is close to mature (ICD -10-CM H25.012). Dr. Ferrara decides to schedule Betty for lens extraction; the procedure is ambulatory care surgery with same-day admission and discharge. The procedure will be done at Mischogie Hospital’s Outpatient Clinic on 5/10/2029. Horizon PPO requires precertification for this procedure (CPT 66984).

PRECERTIFICATION FORM
Insurance carrier
Certification for     admission and/or     surgery and/or
Patient name
Street address
City/state/zip
Telephone                                  Date of birth
Subscriber name
Employer
Member no.                              Group no.
Admitting physician
Provider no.
Hospital/facility
Planned admission/procedure date
Diagnosis/symptoms
Treatment/procedure
Estimated length of stay

Answer 1

Precertification Form

Insurance Carrier: Horizon PPO

Certification for…[x]surgery

Patient name: Elizabeth R. Sinowitcz

Street address: 45 Maple Hill Rd., Apt. 12-B

City/state/zip: Rangeley, MN 55555

Telephone: 555-123-9887        DOB: 08/02/1943

Subscriber name: Elizabeth R. Sinowitcz

Employer: Argon Electric Company

Member number: 65-PO

Admitting physician: Dr. Hank R. Ferrara

Provider number: 349-00-G

Hospital/facility: Mischogie Hospital Outpatient Clinic

Planned admission/procedure date: 05/10/2016

Diagnosis/symptoms: H25.012

Treatment/procedure: 66894

Estimated length of stay: 1 day