Question

The objective of these exercises is to correctly complete Medicaid claims, applying what you have learned in the chapter. Following the information about the provider for the cases are two sections. The first section contains information about the patient, the insurance coverage, and the current medical condition. The second section is an encounter form for Valley Associates, PC.

 

Billing Provider Information

 

Name: Valley Associates, PC

Address: 1400 West Center Street

                 Toledo, OH

                 43601-0213

Telephone: 555-967-0303

Employer ID Number: 16-1234567

NPI: 1476543215

 

Rendering Provider Information

 

Name: David Rosenberg, MD

NPI: 1288560027

Assignment: Accepts

Signature: On File (01/01/2029)

nformation About the Patient:

 

Name: Scott Yeager
Sex: M
Birth Date: 11/17/1974
Marital Status: Single
Address: 301 Maple Ave.
                Sandusky, OH
                44870-4567
Telephone: 555-626-7268
Employer: Unemployed
Race: White
Ethnicity: Not Hispanic or Latino
Preferred Language: English
Insured: Self
Health Plan: Medicaid
Insurance ID Number: 139629748MC
Policy Number: 75324
Group Number: N/A for Medicaid Plans
Copayment/Deductible Amt.: $15 copay
Assignment of Benefits: Y
Signature on File: 10/01/2029
Condition Unrelated to Employment, Auto Accident, or Other Accident

  $Patient_Information_Form_ScottYeager.jpg$