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.



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


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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