HCR 203 Week 2 CMS-1500 Claim Form Worksheet

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HCR 203 Week 2 CMS-1500 Claim Form Worksheet
Resource: CMS-1500 completed claim form and this week's readings

Complete the University of Phoenix Material: CMS-1500 Claim Form Worksheet.

Click the Assignment Files tab to submit your assignment.

CMS-1500 Claim Form Worksheet

 

Complete Part A, B and C of this worksheet.

 

Resource: CMS-1500 Completed Claim Form and Ch. 7 and 17 of Medical Insurance

 

Part A: CMS-1500 Claim Form

 

Imagine you are working at a local medical office as a billing specialist. You are asked to audit the CMS-1500 claim form completed by a new employee to ensure it was completed correctly.

 

Review the Patient Information, Provider Information and Treatment Information.

 

Provider Information
 
Patient Information
Name
John Brown, MD
 
Name
Kevin Luke
Address
12123 South High Street, St. Paul, OH 77831
 
Sex
Male
Telephone
202- 445-0000
 
Birth Date
09/02/1966
Employer ID
00-8885674
 
Address
2233 Campus Ct., Iowaville, Ohio, 77832
NPI
9988775544
 
SSN
000-01-0101
Signature
On file (1-1-2015)
 
Health Plan
Medical Health PPO
 
 
 
Insurance ID number
2229998-23
Treatment Information
 
Group Number
OH333
Dates of Service
01/01/2014
 
Employer
LVL Trucking Inc.
Place of Service
11
 
Account number
18993
CPT
95810- Charge $1100.00 x1
 
 
 
Diagnosis
32723- Sleep apnea
 
 
 
 

Review the CMS-1500 Completed Claim Form document.

 

Determine if the employee input the correct data and completed correctly the data fields in the claim form.

 

Complete the table below by listing the data field completed incorrectly and providing both the incorrect entry and correct entry. An example has been provided.

 

Data Field
Incorrect entry
Correct entry
#26
Patient’s account number listed as 12998
Correct account number is 18993
 

 
 
 
 

 

 
 
 
 

 
 
 
 

 
 
 
 

 
 
 
 

 
 
 
 

 

 
 
 
 

Write 50- to 150-word response to the following question. Be clear and concise, use complete sentences, and explain your answers using specific examples.

 

Cite any outside sources. For additional information on how to properly cite your sources check out the Reference and Citation Generator resource in the Center for Writing Excellence.

 

1.     Explain the importance of complete and accurate completion of the claim form prior to claim processing.

 

2.     How can the payment plan affect reimbursement?

 

Part B: Patient and Insurance Information Section of the CMS-1500 Claim Form

 

Review the Patient Information.

Patient Information



 

Determine the appropriate content for each Data Field Number listed. An example has been provided.

 

Data Field Number
Data Field Content
1
Medicare
1a
 
2
 
3
 
4
 
5
 
6
 
 

Part C: Physician or Supplier Information Section of the CMS-1500 Claim Form

 

Review the note below.



Determine the appropriate content for each Data Field Number listed. An example has been provided.

 

Data Field Number
Date Field Content
21
790.22
24
 
24 F
 
25
 
26
 
28
 
32
 
33
 
 

 
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