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)

Prepare the claim for this case by completing the appropriate fields in the CMS-1500 form provided. Accuracy is important. Please note that tabbing through the form works inconsistently; it is recommended that you click in each field for which you want to enter information. For the purposes of Connect, all dates should be entered in 8-digit format (XX in MM field; XX in DD field; XXXX in YY field) except for Item Number 24, where the dates should be entered in 6-digit format (XX in MM field; XX in DD field; XX in YY field). NOTES: this medical facility does not use an outside lab; the patient’s chart number should be used for the patient account number; we have tried to include information you might need from earlier Case Studies, but please refer back to Chapter 7 if necessary.

From the Patient Information Form:

 

Name: Gwen Remarky
Sex: F
Birth Date: 11/05/1979
Marital Status: Married
Address: 9 Sealcrest Drive.
                Brooklyn, OH
                44144-6789
Telephone: 555-628-9791
Employer: Brooklyn Day Care
Race: White
Ethnicity: Not Hispanic or Latino
Preferred Language: English
Insured: Self
Health Plan: Aetna Choice
Insurance ID Number: BP3333-X89
Policy Number: 96248
Group Number: 152535C
Copayment/Deductible Amt.: $15 copay
Assignment of Benefits: Y
Signature on File: Y (01/01/2029)
Condition unrelated to Employment, Auto Accident, or Other Accident

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