HCS 182 Week 4 The Claims Process

HCS 182 Entire Course Link

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:


1.     Who is the subscriber


2.     What is the group number?


3.     What is the Identification number?


4.     What is the type of Taylor plan?


5.     What is the claim’s address?


6.     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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