Question

The objective of these exercises is to correctly complete private payer 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.

 

The following provider information should be used for Cases 8.4A and 8.4B

 

Billing Provider Information: 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, M.D.

NPI: 1288560027

Assignment: Accepts

Signature: On File (01/01/2029)

From the Patient Information Form:

 

Name: David Belline

Sex: M

Birth Date: 01/22/1968

 

Marital Status: Married

Address: 250 Milltown Rd.

                Alliance, OH

                44601-3456

Telephone: 555-627-1535

Employer: Kinko’s

Race: White
Ethnicity: Not Hispanic or Latino
Preferred Language: English
Insured: Self
Health Plan: Anthem BCBS PPO
Insurance ID Number: 35Z29005
Policy Number: 87526
Group Number: 162537B
Copayment/Deductible Amt.: $20 copay
Assignment of Benefits: Y
Signature on File: Y (06/01/2029)
Condition unrelated to Employment, Auto Accident, or Other Accident

 

Be sure to follow NUCC directions for CMS-1500 claim completion in regards to punctuation in addresses. Related to this, do not include punctuation for Item Number 31. Follow Medicare guidelines and abbreviate street addresses (i.e. ST rather than Street). Per NUCC Guidelines, use SOF in this exercise for Signature on File if appropriate. Also, per NUCC guidelines, do not include the decimal point in the diagnosis code(s) entered in Item Number 21. Functionality TIP: if you can't see the entire form and don't have scroll bar functionality (especially if you click "Check my work"), click anywhere in the form and use the arrow keys on your keyboard to help you navigate.