HCS 182 Week 4 The Claims Process

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 HCS 182 Week 4 The Claims Process

Resources: Claims Process Worksheet, CMS 1500 Claim Form

Complete parts A, B, and C of the Claims Process Worksheet.

Click the Assignment Files tab to submit the Claims Process worksheet and the CMS 1500 Claim Form.

Part A: Read the following scenario:


Mrs. Jane Sample (DOB 12/22/1967) called her primary care provider’s office and scheduled an appointment with Dr. Billings for Monday, October 22nd, 2015. She requested the appointment because she had a cough and some congestion as well as wheezing and a fever off and on for about three days prior. Upon registration, she informed the front desk that she had new insurance effective October 1, 2015.


The insurance card was scanned and the following information was verified:




Name: Jane Sample


DOB 12/22/1967


Address: 211 First Lane


 Houston, TX 77398




Phone Number: (555) 727-5555


Insurance Subscriber: John Sample  




DOB: 5/25/1965





The doctor examined Mrs. Sample and felt that due to the wheezing, a chest X-ray was needed to determine if pneumonia was present. This patient has had a history of pneumonia, so it was medically necessary to evaluate the present signs and symptoms. The chest X-ray did reveal left lobe pneumonia.


Mrs. Sample was given prescriptions for Erythromycin 500mg three times daily, Prednisone 5mg once daily, and Tessalon Pearls as needed for cough every four hours.


Dr. Billings filled out the encounter form with the following information:




Office Visit level of service: 99214   Charges: 150.00


Chest xray: 71020   Charges: 125.00


Diagnosis: Left Lower Lobe Pneumonia  J18.1


Ralph Billings MD


777 Smith Avenue


Houston, TX 77398


Phone (555) 555-5555


NPI: 1234567891



Part B: Mrs. Sample indicated that her insurance was new as of October 1st. Looking at the card below, please answer the following:





Who is the subscriber






What is the group number?






What is the Identification number?






What is the type of Taylor plan?






What is the claim’s address?






What is the copay listed for PCP?




Part C: Collecting accurate claim’s data ensures the likelihood of creating a clean claim. Using the information in the scenario in Part A, open the CMS_1500_Claim_Form and fill in the following fields of the 1500 claim form:




Sections 1-11


Section 21


Section 24: lines 1 and 2


Section 28


Section 33
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