student assignment pack 2

Student Assignment

Pack 2

e0205502AS02B-54

Medical Coding and Billing Specialist

Assignment Pack 2

e0205502AS02B-54 3

Mail-in Quiz 11

Select the best answer from the choices provided. Each item is worth 5 points.

1. DRG stands for _____.a. digital relations groupb. diagnosis related groupc. diagnostic retroactive guaranteed. diagnosis review group

2. The initial goal of DRGs was to _____.a. determine what doctors were charging for specific diagnosesb. classify each patient by his/her type of visitc. determine the average charges for proceduresd. establish a classification system for patients and their

required treatments

3. DRGs are changing reimbursement from a(n) _____ system.a. lump-sum fee system to a fee-for-serviceb. fee-for-service system to a lump-sum feec. peer review system to a fee-for-serviced. inpatient to an outpatient

4. The DRGs are classified into _____ based on a specific organ system of the body.a. outliersb. major diagnostic categoriesc. diagnostic related categoriesd. APCs

5. _____ are cases that require patients to have additional time in the hospital or variations in treatments.a. DRGsb. APCsc. Outliersd. Variation cases


4 e0205502AS02B-54

6. _____ is a factor considered when the DRG rate is determined.a. The principal diagnosisb. Secondary diagnosisc. The age and sex of the patientd. All of the above

7. APC is a payment system _____.a. based on procedures performed per visitb. for outpatient procedure codesc. that utilizes the procedure as the initial variable in the

classification processd. all of the above

8. _____ are factors of the nationally uniform relative value.a. Malpractice expensesb. Usual, customary and reasonable standardsc. Prevailing chargesd. Actual charges

9. Charges that exceed the UCR scale of a policy are _____ by the carrier.a. allowed b. paid anywayc. disallowedd. always applied toward the deductible

10. A _____ is an individual who reviews current physicians’ fee schedules to make sure they are in line with DRGs.a. physician superintendentb. DRG monitorc. DRG administratord. PRO president

11. A medical practice involved in a managed care contract, such as an HMO or PPO, _____.a. primarily uses the customary fee scale to determine paymentb. may have several fee schedulesc. is required to use the Resource Based Relative Value System (RBRVS)d. is managed by a DRG monitor

Assignment Pack 2

e0205502AS02B-54 5

Match the descriptions with the corresponding classification system. Each question is worth 5 points.

12. _____ Used primarily in same day surgery centers, emergency departments or clinics

13. _____ Uses only ICD-9-CM diagnoses and CPT procedures

14. _____ A case can be assigned to only one

15. _____ A case can be assigned to many

16. _____ Based on ICD-9-CM diagnoses and procedures, age, sex and discharge disposition

17. _____ Utilizes the procedure as the initial variable in the classification process

18. _____ Classified by an admission

19. _____ Developed by two Yale professors

20. _____ Utilizes the diagnosis as the initial variable in the classification process

a. APCb. DRG


6 e0205502AS02B-54

Assignment Pack 2

e0205502AS02B-54 7

Mail-in Quiz 12

For the following items, choose the best term to complete each sentence. Not all terms will be used. None of the terms will be used more than once. Each item is worth 5 points.

afferent

anatomy

ascending

backward

can

cannot

cardiovascular

caudad

cell physiology

coronal

deep

descending

dorsal

efferent

endocrine

forward

human biology

inferior

lateral

longitudinal

macroscopic anatomy

microscopic anatomy

monumental anatomy

morphology

parasagittal

pathology

pathophysiology

physiology

posterior

respiratory

sagittal

superior

three

transverse

two

xenology

xenomorphology

zoology

1. The study of how the body is put together and how it works in health and disease is called ______________________________________.

2. The science of the structure of the body is called __________________________.

3. There are _________________ kinds of anatomy.

4. Anatomy that includes parts of the body too small to be seen by the naked eye is called ______________________________________________.

5. The study of how the body works is ______________________________________.

6. The names of body parts, the location of body parts and the relationship of two or more body parts all are included in _____________________________.

7. Microscopic physiology is usually called _______________________________.

8. The study of human biology when anatomy and/or physiology is abnormal is called __________________________________________.

9. A person ________________ have abnormal physiology and normal anatomy.

10. Abnormal physiology is sometimes called ________________________________.


8 e0205502AS02B-54

11. The ______________________________ branch of a nerve carries a message to the brain from a muscle.

12. A(n) __________________________ artery carries blood away from the heart.

13. A sagittal plane made slightly to one side or the other of the midline is called a(n) ________________________________________ plane.

14. The heart, blood vessels and lymph vessels are part of the ______________________________________ system.

15. If a doctor describes the size, shape, color, contour and texture of a body part, he is talking about _______________________________________.

16. In the anatomic position, the chin is anterior and ____________________ to the heel.

17. The antonym of superficial is ____________________________________________.

18. A(n) _____________________________ plane divides the body into superior and inferior sections.

19. The opposite of ventral is _______________________.

20. In the anatomic position, the palms of the hands are facing _______________.

Fold on dotted lineThis Space for Instructor Use

1. Fill in your student ID and your course code below.

STUDENT ID NUMBER COURSE CODE

2. Be sure your name and address are filled in below.3. Mark your answers on this cover sheet.

NAME

ADDRESS

CITY STATE ZIP

U.S. Career Institute2001 Lowe StreetFort Collins, CO 80525

CB1

For School Use Only: Grade: ___________

e0205502AS02B-54 9

Medical Coding and Billing SpecialistMail-in Quiz 12

1. _____________________________________________________________

2. _____________________________________________________________

3. _____________________________________________________________

4. _____________________________________________________________

5. _____________________________________________________________

6. _____________________________________________________________

7. _____________________________________________________________


10 e0205502AS02B-54

8. _____________________________________________________________

9. _____________________________________________________________

10. _____________________________________________________________

11. _____________________________________________________________

12. _____________________________________________________________

13. _____________________________________________________________

14. _____________________________________________________________

15. _____________________________________________________________

16. _____________________________________________________________

17. _____________________________________________________________

18. _____________________________________________________________

19. _____________________________________________________________

20. _____________________________________________________________

Assignment Pack 2

e0205502AS02B-54 11

Mail-in Quiz 13

Choose the best answer from the choices provided. Remember, you may use your flashcards to answer these items. Each item is worth 5 points.

1. _____ anatomy refers to the study of body parts and systems that can be seen without the aid of a microscope.a. Microscopicb. Epithelialc. Grossd. Cellular

2. The study of the surface of the body is often called _____ anatomy.a. surfaceb. superficialc. subdurald. supine

3. When the body is _____, it is lying flat on its back.a. supineb. pronec. transversed. superficial

4. When the body is lying _____, it is face down.a. supineb. pronec. transversed. subdural

5. When doctors examine the abdomen, they mentally divide the abdomen into _____ areas or regions.a. sixb. ninec. twod. three


12 e0205502AS02B-54

6. A simpler method of division is the quadrant method. Each quadrant is _____ of the abdominal region.a. one-fourthb. one-halfc. one-tenthd. one-fifth

7. Body cavities have two functions: _____ the organs and keeping the organs in a fairly constant location.a. nourishingb. developingc. movingd. protecting

8. The two principal body cavities are the _____ body cavity and the ventral body cavity.a. centralb. nervousc. craniald. dorsal

9. Body membranes come from two basic tissue groups: _____ tissue and connective tissue.a. endocrineb. exoskeletalc. epitheliald. serous

10. Epithelial membranes include _____ membrane, mucous membrane and serous membrane.a. cutaneousb. cranialc. connectived. keratinized layer

11. The mucous membranes often secrete _____, which prevents body cavities from drying out.a. melatoninb. lymphc. mucusd. serosa

Assignment Pack 2

e0205502AS02B-54 13

12. Muscle tissue _____.a. covers every surface of the bodyb. connects other types of tissuesc. can extend and contractd. makes up the spinal cord and peripheral nerves

13. The brain and spinal cord are protected by _____.a. thoracic fluidb. meningesc. the mediastinumd. mucus

14. The largest serous membrane of the body is called the _____, and it protects the abdominopelvic cavity.a. peritoneumb. craniumc. thoracicald. synovial membrane

15. An organ outside of the abdominal cavity is known as a _____ organ.a. meninxb. retroperitonealc. dysfunctionald. systemic

16. The _____ line the joints of the shoulders, knees and toes.a. spinal meningesb. parietal peritoneumc. synovial membranesd. cutaneous membranes

17. _____ tissue covers every surface of the body. a. Connectiveb. Epithelialc. Muscled. Brain


14 e0205502AS02B-54

18. _____ tissue connects other types of tissues.a. Connectiveb. Epithelialc. Muscled. Brain

19. _____ is the smallest unit in the body.a. A systemb. A cellc. Tissued. A membrane

20. In your job, you encounter the phrase, “RLQ pain—onset and history not typical for appendicitis.” You know that the acronym RLQ stands for _____.a. right or left quadrantb. right lower quadrantc. really lasting quinined. region of lower quadrant

Assignment Pack 2

e0205502AS02B-54 15

Mail-in Quiz 14

Each item is worth 5 points.

Choose the best answer from the choices provided.

1. _____ are the building blocks of the body. a. Cellsb. Tissuesc. Organsd. Organ systems

2. The _____ is made up of proteins, lipids and carbohydrates that provide energy to the cell.a. DNAb. nucleusc. cell membraned. cytoplasm

3. _____ contains other cellular structures called organelles.a. RNAb. Cytoplasmc. The cell membraned. The Golgi apparatus

4. Lysosomes are membrane-bound bodies, or sacs of _____, in the digestive part of the cell. a. waterb. carbohydratesc. proteind. enzymes

5. The _____ is an organelle that packages proteins and other products of a cell for delivery to the rest of the body.a. Golgi apparatusb. ribosomec. centrioled. vacuole


16 e0205502AS02B-54

6. _____ is a term used for any diseases or conditions where the etiology is unknown. a. Idiopathicb. Inflammationc. Iatrogenicd. Immunologic

7. Intracellular accumulation is a type of _____.a. tissue deathb. cell adaptationc. allergic reactiond. inflammation

8. Inflammation has _____ symptoms or signs.a. no visibleb. threec. fourd. many

9. _____ is caused when swelling of the tissues pinches nerve cells. a. Rednessb. Deathc. Agingd. Pain

10. Pseudomembranous inflammation is a form of _____ inflammation combined with fibrinopurulent drainage.a. granulomatousb. subacutec. ulceratived. chronic

Assignment Pack 2

e0205502AS02B-54 17

Match the term with its definition. Each item is worth 5 points.

11. _____ Hypoxia

12. _____ Viruses

13. _____ Aging of the cell

14. _____ Trauma

15. _____ Metabolic/genetic

16. _____ Atrophy

17. _____ Allergic/immune reactions

18. _____ Metaplasia

19. _____ Necrotic

20. _____ Chronic inflammation

a. Infections that don’t completely heal, slow injury- and slow allergic irritation

b. The decreased availability of oxygen to the cells

c. Injury caused by the inappropriate application of force or toxic agents

d. Disorders in which the body’s defense mechanisms try to destroy their own cells

e. Diabetes mellitus and Tay-Sachs disease are examples of this type of cell injury

f. Occurs when cells change from one type to another

g. Type of microbial pathogens that invade cells and destroy them

h. The natural process that causes illness and eventual death due to cells being unable to regenerate

i. The term used to describe decreases in size of a cell, tissue, organ or body

j. Tissues where cells are damaged and unable to be repaired or regenerated


18 e0205502AS02B-54





NAME

ADDRESS

CITY STATE ZIP


CB1


e0205502AS02B-54 19


1. ________________

2. ________________

3. ________________

4. ________________

5. ________________

6. ________________

7. ________________

8. ________________

9. ________________

10. ________________


20 e0205502AS02B-54

11. ________________

12. ________________

13. ________________

14. ________________

15. ________________

16. ________________

17. ________________

18. ________________

19. ________________

20. ________________

Assignment Pack 2

e0205502AS02B-54 21

Mail-in Quiz 15

Complete the sentences by filling in the blanks with the correct word(s). Each item is worth 2 points.

1. The three sections of the CMS-1500 form that should be completed are the: ___________________, _____________________________________ and the ________________________________________ sections.

2. When you have completed the claim form, you should always _________________________ the form to make sure that all of the information recorded is complete and accurate.

3. Field(number)____________identifiesthepatient’sinsuranceprogramdesignation for this claim.

4. If the patient is pregnant, Field (number) _________ requires the date of the LMP, which stands for _____________________________________________.

5. Although you should enter SIGNATURE ON FILE in Field 13 for patients withprivateinsurancecarriers,thefieldshouldbeleftblankforMedicaidpatients, for __________________ patients who do not have a Medigap policy, forworkers’compensationpatientsoriftheofficecollectspaymentinfullfrom patients at the time of service.

6. With the exception of Medicare and Medicaid, if the patient has secondary coverageunderanotherhealthbenefitplan,youshouldtypeanX in the YES box in Field (number) ____________.

7. Dr. Ted Brown referred Alice Smith to Dr. Albert Sands. Dr. Brown’s name shouldbeenteredinField(number)____________whenDr.Sands’officesubmits the claim form.

8. Complete diagnosis codes are entered in Field (number) ____________.

9. The amount of the individual charges being billed for each procedure performed is entered in Field (number) ____________.

10. If an X is typed in the YES box in Field 11d, information about the patient’s secondary insurance coverage should be entered in Fields (numbers) ____________ through ____________.

11. If a patient has work done by a laboratory outside the physician’s office, the charges for the laboratory services are entered in Field (number) ____________.


22 e0205502AS02B-54

12. You must refer back to Field (number) ____________ in order to fill in the diagnosis code for Field 24E.

13. In Field 25, if you have both an EIN and a SSN for the physician, you use the ____________.

14. ____________________ codes and appropriate _________________ are entered in Field 24D.

15. Once you complete a claim form, proofread it for ______________________.

Quiz continues

Assignment Pack 2

e0205502AS02B-54 23

For items 16 and 17, complete the CMS-1500 form as directed. Blank claim forms are located after item 17. Each claim form is worth 35 points.

16. Complete the entire CMS-1500 claim form for Brenton Niles, using the encounter form below.

NilesHobitPIF Q15

Fred Hobit, MD24 Mockingbird LaneYoungstown, CO 80004(970) 555 -2024

Patient InformationName Brenton Niles Date of Birth 04-15-2000 Address 2777 Lincoln Ave Sex Male Marital Status Single City Youngstown State CO ZIP 80004Home Phone 970-555-9111

Employment InformationName of Employer Occupation Student X Full time Part-time

Insurance InformationPrimary Insurance Secondary InsuranceName Net Life Name Blue Cross of CO ID# 300-00-0848 ID# 768311900 Group# 629 Group# 318 Address PO Box 32 Address PO Box 99 City Youngstown City Youngstown State CO ZIP 80004 State CO ZIP 80004 Primary Insured Name Gary Niles Secondary Insured Name Theresa Niles Relation to Patient father Relation to Patient mother DOB 1-29-1967 DOB 11-16-1967 Employer Western Bell Employer Family Clinic I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Gary Niles Signature of patient (or parent of minor child)

I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Theresa Niles Signature of patient (or parent of minor child)

Physician signature: Fred Hobit, MD SSN: 801-00-0150 NPI: 0155011830 Participating Provider for: All private insurance

Date of Service 11-18-XX Diagnosis Procedure Charge 841.9 Elbow sprain 99212 Est. patient level 2 $50.00

Today’s Charge $50.00 Cash/Check $0.00 Balance $50.00


24 e0205502AS02B-54

17. Complete the entire CMS-1500 claim form for Bonnie Schmidt using the encounter form below.SchmidtHobitPIF

Fred Hobit, MD 24 Mockingbird Lane Youngstown, CO 80004 (970) 555-2024

Patient Information Name Bonnie Schmidt Date of Birth June 25, 1952 Address 1810 Bluegrass Drive Sex F Marital Status Married City Springtown State CO ZIP 80002 Home Phone 970-555-9041

Employment Information Name of Employer Kain Graphics Address 1294 Main Street City Springtown State CO ZIP 80002 Phone Occupation Graphic design Student Full-time Part-time

Insurance Information Primary Insurance Secondary Insurance Name HSI Name CHAMPVA ID# 560-00-1113 ID# 635-00-7213 Group# 208 Group# Address PO Box 324 Address 4500 Cherry Creek Drive South, Box 64 City Springtown City Denver State CO ZIP 80002 State CO ZIP 80222 Primary Insured Name Bonnie Secondary Insured Name Richard Schmidt Relation to Patient self Relation to Patient spouse DOB June 25, 1952 DOB Sept 15, 1952 Employer Kain Graphics Employer USAF I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Bonnie Schmidt Signature of patient (or parent of minor child)


Richard Schmidt Signature of patient (or parent of minor child)

Physician signature: Fred Hobit, MDSSN: 801-00-0150 NPI: 0155011830 Participating Provider for: All private insurance Date of Service 5-6-XX Diagnosis Procedure Charge 727.1 Bunion 99211 Est. patient level 1 $45.00 Today’s Charge $45.00 Cash/Check $5.00 Balance $40.00

Assignment Pack 2

e0205502AS02B-54 25

16. Brenton Niles, CMS-1500 claim form.CMS 1500 BLANK FORM 1500

HEALTH INSURANCE CLAIM FORM

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

PICA PICA 1. MEDICARE MEDICAID TRICARE

CHAMPUS CHAMPVA GROUP

HEALTH PLAN FECA BLK LUNG

OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)

(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) (SSN or ID) (SSN) (ID) 2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)

M F 5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)

Self Spouse Child Other CITY STATE 8. PATIENT STATUS CITY STATE

Single Married Other ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)

Employed Full-TimeStudent Part-Time

Student 9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX

MM DD YY

YES NO M F b. OTHER INSURED’S DATE OF BIRTH SEX MM DD YY

b. AUTO ACCIDENT? Place (State) b. EMPLOYER’S NAME OR SCHOOL NAME

M F YES NO c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME

YES NO d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

YES NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below.

SIGNED DATE SIGNED

14. DATE OF CURRENT MM DD YY ILLNESS (First symptom) OR

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, GIVE FIRST DATE MM DD YY

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD YY

INJURY (Accident) OR FROM TO PREGNANCY (LMP) 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

MM DD YY MM DD YY

17b. NPI FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES

YES NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION

1. . 3. . CODE ORIGINAL REF. NO.

2. . 4. . 23. PRIOR AUTHORIZATION NUMBER

24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J. From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS OR EPSDT ID. RENDERING

MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS FAMILY QUAL. PROVIDER ID. # 1.

NPI 2.

NPI 3.

NPI 4.

NPI 5.

NPI 6.

NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE

YES NO $ $ $ 31. SIGNATURE OF PHYSICIAN OR SUPPLIER

INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.

32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #

SIGNED DATE

a. b. a. b.


26 e0205502AS02B-54

17. Bonnie Schmidt, CMS-1500 claim form.CMS 1500 BLANK FORM 1500














MM DD YY








SIGNED DATE SIGNED





MM DD YY MM DD YY







NPI 2.

NPI 3.

NPI 4.

NPI 5.

NPI 6.





SIGNED DATE

a. b. a. b.





NAME

ADDRESS

CITY STATE ZIP



e0205502AS02B-54 27

CB2


Please Print

1. __________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

2. _________________________

3. _________________________

4. _________________________

_________________________

5. _________________________

6. _________________________

7. _________________________

8. _________________________

9. _________________________


28 e0205502AS02B-54

10. ___________ ____________

11. _________________________

12. _________________________

13. _________________________

14. _________________________

_________________________

15. _________________________

16 & 17. Submit with your completed CMS-1500 claim forms.

Assignment Pack 2

e0205502AS02B-54 29

Mail-in Quiz 16

Complete the following sentences by filling in the blanks with the correct words. Each item is worth 4 points.

1. Another name for the UB-04 claim form is the _________________ claim form.

2. In 1993, hospitals began to use the UB-04 form to bill ______________________.

3. A beneficiary’s lifetime reserve days for the first calendar year under Medicare are entered in FL 39 as a code ______________.

4. In FL 10, the patient’s birth date is entered using eight characters coded in this format: _____________________________.

5. For FL 16, recording the discharge hour is not required for _________________.

6. FL 46 contains the number of _______________________ or times a procedure was performed.

7. The principal diagnosis may be different from the ______________ diagnosis.

8. The ICD-9-CM code that describes the principal ________________ is entered in FL 67.

9. FL 74 records the ___________________________ procedure code and date for inpatient claims.

10. The attending physician’s name and NPI number are entered in FL (number) ____________.


30 e0205502AS02B-54

Use this UB-04 for items 11 through 25.

LESSON 21MEDICAL CLAIMS AND BILLING SPECIALIST

0201403LB34C-21-5021-42

1 2 4 TYPEOF BILL

FROM THROUGH5 FED. TAX NO.

a

b

c

d

DX

ECI

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

A

B

C

A B C D E F G HI J K L M N O P Q

a b c a b c

a

b c d

ADMISSION CONDITION CODESDATE

OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE SPAN OCCURRENCE SPANCODE DATE CODE CODE CODE DATE CODE THROUGH

VALUE CODES VALUE CODES VALUE CODESCODE AMOUNT CODE AMOUNT CODE AMOUNT

TOTALS

PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE NPICODE DATE CODE DATE CODE DATE

FIRST

c. d. e. OTHER PROCEDURE NPICODE DATE DATE

FIRST

NPI

b LAST FIRST

c NPI

d LAST FIRST

UB-04 CMS-1450

7

10 BIRTHDATE 11 SEX 12 13 HR 14 TYPE 15 SRC

DATE

16 DHR 18 19 20

FROM

21 2522 26 2823 27

CODE FROMDATE

OTHER

PRV ID

THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

b

.INFO BEN.

CODEOTHER PROCEDURE

THROUGH

29 ACDT 30

3231 33 34 35 36 37

38 39 40 41

42 REV. CD. 43 DESCRIPTION 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49

52 REL51 HEALTH PLAN ID

53 ASG.54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI

57

58 INSURED’S NAME 59 P.REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

66 67 68

69 ADMIT 70 PATIENT 72 73

74 75 76 ATTENDING

80 REMARKS

OTHER PROCEDURE

a

77 OPERATING

78 OTHER

79 OTHER

81CC

CREATION DATE

3a PAT.CNTL #

24

b. MED.REC. #

44 HCPCS / RATE / HIPPS CODE

PAGE OF

APPROVED OMB NO. 0938-0997

e

a8 PATIENT NAME

50 PAYER NAME

63 TREATMENT AUTHORIZATION CODES

6 STATEMENT COVERS PERIOD

9 PATIENT ADDRESS

17 STAT STATE

DX REASON DX71 PPS

CODE

QUAL

LAST

LAST

National UniformBilling CommitteeNUBC

™

OCCURRENCE

QUAL

QUAL

QUAL

CODE DATE

A

B

C

A

B

C

A

B

C

A

B

C

A

B

C

a

b

a

b

ROCKY MOUNTAIN HOSPITAL CS2473A

5454 AUDUBON WAY SC5526CA 0111

YOURTOWN, CO 80001

970 555 5555 550000009 0122XX 0123XX

2621 KINGS CT

SANCHEZ ROCKY YOURTOWN CO 80000

08211957 M 0122XX 1 7 01

72 0122XX 0122XX

01 1250 00

XXXX SEMIPRIVATE ROOM 125000 0122XX 1 1250 00

XXXX US CARDIAL 0122XX 1 535 00

0001 1 1 0122XX 1785 00

6565886565

MEDICARE 6565886565 4

SANCHEZ ROCKY 18 325001926A

FM3321

42090

9

78650

0275695402

PHILLIPS CLIFFORD

2 03

3

Y

Y

8872 0122XX

2621 KINGS COURT55-0000009

Assignment Pack 2

e0205502AS02B-54 31

Fill in the blanks using the UB-04 for Rocky Sanchez. Each item is worth 2 points.

11. What code is entered for the type of bill? ____________

12. Rocky Sanchez was discharged to his home. The discharge status is found in FL ____________.

13. The source of the referral for this admission is indicated in FL ____________.

14. SC5526CA is the __________________________________ number.

15. Code 01 in FL 39 tells us the room Rocky stayed in was ____________________.

16. Rocky’s patient control number is located in FL ____________.

17. The revenue code that indicates total charges is ____________.

18. Who is the primary insurance carrier? _________________________

19. Who is the primary insured? ____________________________________

20. The NPI number for the billing provider is __________________________.

21. The NPI number assigned to the attending physician is ____________________.

22. Is a principal procedure listed? _______________

23. The principal diagnosis code is _______________.

24. Treatment authorization code __________________________ tells us that preauthorization was obtained for these services.

25. According to FL (number) ___________, Rocky has given permission for his medical information to be released in order to process this claim.


32 e0205502AS02B-54





NAME

ADDRESS

CITY STATE ZIP



e0205502AS02B-54 33

CB2


1. ______________________________

2. ______________________________

3. ______________________________

4. ______________________________

5. ______________________________

6. ______________________________

7. ______________________________

8. ______________________________

9. ______________________________


34 e0205502AS02B-54

10. ______________________________

11. ______________________________

12. ______________________________

13. ______________________________

14. ______________________________

15. ______________________________

16. ______________________________

17. ______________________________

18. ______________________________

19. ______________________________

20. ______________________________

21. ______________________________

22. ______________________________

23. ______________________________

24. ______________________________

25. ______________________________

Assignment Pack 2

e0205502AS02B-54 35

Important Notice about MedLook QuizzesDear Student:

We have an important update about your quizzes that instruct you to use MedLook, the billing software that is used in your course. Because it has come to our attention some students were experiencing technical difficulties in printing or saving and submitting claim forms from MedLook, you may now submit all claim form quizzes (except the final practicum) using the PDF claim form download available on your student site.

It is important that you complete the practice exercises and assignments in all lessons. The final assignment in your course includes claim forms that will require you to use MedLook to submit your quiz answers. You will be glad you took the time to gain a good understanding of the software in the practice exercises to complete the final lesson.

This change is a result of our valued student input and we do not want your studies to slow down due to technical difficulties. If you are having difficulties using MedLook, please contact the instruction department at your convenience to troubleshoot MedLook before you reach the final quiz.

Thank you and good luck with your studies.


36 e0205502AS02B-54

Assignment Pack 2

e0205502AS02B-54 37

Mail-in Quiz 17

Choose the best answer from the choices provided. Each item is worth 3 points.

1. A clearinghouse is a(n) __________. a. discount retail store b. provider’s computer system c. business that formats, edits and transmits claims d. insurance company

2. Insurance companies are known as __________. a. providers b. payers c. clearinghouses d. modems

3. A clearinghouse is a company that processes claims information into standardized formats and then __________. a. stores the claims in a warehouse b. submits the claims to insurance companies c. fills out CMS-1500 forms d. sends the claims to patients

4. Electronic billing provides electronic acknowledgement that a transaction was received, proving __________. a. substantial time savings b. monetary savings c. eligibility benefits d. timely filing

5. When data is entered in a computer record, it becomes __________. a. digitized b. an electronic transaction c. transmitted d. downloaded


38 e0205502AS02B-54

6. Which of the following is NOT a reason that using a computer to file claims is beneficial? __________ a. It saves paper. b. It saves time. c. It saves money. d. It is more expensive.

7. Direct deposit allows an insurance company to __________. a. send a check to a physician b. send cash to the medical billing specialist c. electronically transfer funds to a physician’s account d. keep better accounting records

8. Carrier-direct claim submission means that, when you work as a medical coding and billing specialist, you need to __________.a. transmit claims directly to the insurance company b. transmit claims directly to the clearinghouse c. file two copies of each claim, one with a clearinghouse and one with the

insurance company d. submit paper claims only

9. One of the answers to the rise in healthcare costs is __________.a. the switch from the EHR to a paper record b. the switch from a paper record to the EHR c. to have fewer people get sick d. better

10. Which of the following is NOT a function of the EHR? __________a. It can alert the physician of allergies. b. It provides the physician with more information. c. All records are accessible to all providers. d. It can remind the physician a prescription needs to be filled.

11. Which of the following is NOT considered hardware? __________a. Keyboard b. Mouse c. Disc drives d. Windows

Assignment Pack 2

e0205502AS02B-54 39

12. The temporary memory your computer uses while running a software application is called __________.a. the hard drive b. the disk drive c. ROM d. RAM

13. The permanent memory your software application is installed to is called __________.a. the hard drive b. the disk drive c. ROMd. RAM

14. A software application that uses forms for data entry and allows you to choose specific data to be displayed in a report is called __________.a. a spreadsheet b. a database program c. e-mail d. a word processing program

15. Windows is __________.a. the least popular operating system b. a graphical interface operating system c. both a and b d. the predecessor of DOS

16. Which of the following is NOT an element of Windows? __________a. Minimize button b. Maximize button c. Menu bar d. Version bar

17. The ___________ Bar houses the command buttons and icons.a. Titleb. Menuc. Ribbond. Task


40 e0205502AS02B-54

18. A window is opened, but it is too small. You will need to __________ the window. a. maximize b. close c. minimize d. drag

19. To enter a new patient in the MedLook program, you will select Patients, and New Patient from ___________ on the main menu bar. a. File b. Activities c. Reports d. Folders

20. Entering information into the patient database __________.a. can be initiated from Tools in the main menu bar b. is not an option in MedLook c. is a step that the provider must complete d. allows you to enter a charge for the patient

Assignment Pack 2

e0205502AS02B-54 41

For items 21 and 22, you will follow the steps provided. Each claim form is worth 20 points.

For this portion, you will submit the claims you completed using the MedLook billing software.

To submit a claim to your instructor by mail or fax, please print your claim as follows: From Billing – F8, select the date of the charge. Click View/eClaims, and then click Print, select your printer and click Print again. A dialog box will ask Print Current Page (Yes) or All Pages (No)? You will select No so the entire claim prints on one page.

To submit a claim to your instructor by e-mail, please do as follows: Once you complete your claim in MedLook, select the date of the charge and then click View/eclaims on your patient’s Billing – F8 page. Your claim will display on the screen; do not close the claim. To submit the claim electronically, the Print Screen function lets you copy a picture of your entire display screen and paste it into a Word document. Just follow these steps.

Open a new Word document into which you will put your Print Screen.

Save the blank document to your computer as Print Screen [Your Name].

Leave the document open.

Click on your claim to maximize it on your screen.

Find the Print Screen key on your keyboard. (It probably is on the top row of keys to the right of the F12 key.) It may be labeled Print Screen, PrtSc or PrtScn. If the label is on the top of the key and another label is on the bottom, you need to use the Shift key when you press the key.

Press the Print Screen key (or Shift key+Print Screen key) now.

Go to the Print Screen document you just opened.

Click inside it to be sure the cursor is active in the document.

Right click.

Choose Paste.

You should see a picture of your completed claim in the Word window. You may need to complete the Print Screen function two or three times to display your entire claim form. (In other words, you may need to create a Print Screen of the top of your claim form, and paste that Print Screen in Word. Then, you may need to scroll in MedLook to display the bottom of your claim form, create a Print Screen of that portion of the form, and paste that Print Screen in to your Word document, too.) Your instructor must be able to view all fields for credit.

Include answers to questions 1 through 20. Also, make sure you include your student information.

Save and close your Word document.


42 e0205502AS02B-54

21. Use the following encounter form to create a claim in MedLook.

CavelloDuncan Ls17 Q41 PIF

Sarah Duncan, MD 1414 Swallow Street Yourtown, CO 80000 (970) 555 -1514

Patient Information Name Andy Cavello Date of Birth January 15, 1997 Address 883 Claybasket Circle Sex male Marital Status single City Anytown State CO ZIP 80001 Home Phone 970-555-8812 Work Phone Cell Phone E-mail address

Employment Information Name of Employer Occupation Student X Full time Part time

Insurance Information Primary Insurance Secondary Insurance Name Blue Cross of CO Name Cigna ID# 630-00-0099A ID# 119001031 Group# BM630 Group# 448C Address PO Box 67 Address 1212 Drake City Denver City Yourtown State CO ZIP 80217 State OH ZIP 01012 Primary Insured Name Mark Cavello Secondary Insured Name Cecelia Cavello Relation to Patient father Relation to Patient mother DOB July 6, 1968 DOB Oct 9, 1970 Employer Beaver Market Employer Advanced Engineering I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Mark Cavello Signature of patient (or parent of minor child)


Cecelia Cavello Signature of patient (or parent of minor child)

Physician signature: Sarah Duncan, MD SSN: 333-33-0003 NPI: 0203048901 Participating Provider for: Blue Cross, Mutual Life and Medicare Date of Service 10-10-20XX Diagnosis Procedure Charge 382.9 Otitis media 99212 Est. patient level 2 $50.00 Today’s Charge $50.00 Cash/Check $0.00 Balance $50.00

Assignment Pack 2

e0205502AS02B-54 43

22. Use the following encounter form to create a claim in MedLook.BloomquistHahns Ls17 Q42PIF

James Hahns, MD 800 Medical Court Yourtown, CO 80000 (970) 555-2222

Patient Information Name Rebecca Bloomquist Date of Birth June 25, 1997 Address 409 Yorkshire Sex F Marital Status single City Yourtown State CO ZIP 80001 Home Phone 970-555-5875 Work Phone Cell Phone E-mail address

Employment Information Name of Employer Occupation Student X Full-time Part-time

Insurance Information Primary Insurance Secondary Insurance none Name Med Link HMO Name ID# 521 00 900602 ID# Group# WBHMO Group# Address PO Box 560 Address City Yourtown City State CO ZIP 80001 State ZIP Primary Insured Name Dick Bloomquist Secondary Insured Name Relation to Patient Father Relation to Patient DOB March 10, 1967 DOB Employer Wilton Bookstore Employer I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Dick Bloomquist Signature of patient (or parent of minor child)


Signature of patient (or parent of minor child)

Physician signature: James Hahns MD SSN: 900-00-9000 NPI: 0405674390 Participating Provider for: Medicaid and all private insurance Date of Service 11/27/XX Diagnosis Procedure Charge 491.9 Chronic Bronchitis 99213 Est. Patient Visit $63.00 Today’s Charge $63.00 Cash/Check $0.00 Balance $63.00


44 e0205502AS02B-54





NAME

ADDRESS

CITY STATE ZIP



e0205502AS02B-54 45


CB2

1. __________

2. __________

3. __________

4. __________

5. __________

6. __________

7. __________

8. __________

9. __________

10. __________

11. __________

12. __________

13. __________

14. __________

15. __________

16. __________

17. __________

18. __________

19. __________

20. __________

Include your MedLook claim forms for items 21-22 when you submit your Quiz to the school.


46 e0205502AS02B-54

Assignment Pack 2

e0205502AS02B-54 47

Mail-in Quiz 18

For this Quiz, you will submit the claims you completed using the MedLook billing software.

To submit a claim to your instructor by mail or fax, please print your claim as follows: From Billing – F8, select the date of the charge. Click View/eClaims, and then click Print, select your printer and click Print again. A dialog box will ask Print Current Page (Yes) or All Pages (No)? You will select No so the entire claim prints on one page.

To submit a claim to your instructor by e-mail, please do as follows: Once you complete your claim in MedLook, select the date of the charge and then click View/EClaims on your patient’s Billing – F8 page. Your claim will display on the screen; do not close the claim. To submit the claim electronically, the Print Screen function lets you copy a picture of your entire display screen and paste it into a Word document. Just follow these steps.

Open a new Word document into which you will put your Print Screen.

Save the blank document to your computer as Print Screen [Your Name].

Leave the document open.

Click on your claim to maximize it on your screen.

Find the Print Screen key on your keyboard. (It probably is on the top row of keys to the right of the F12 key.) It may be labeled Print Screen, PrtSc or PrtScn. If the label is on the top of the key and another label is on the bottom, you need to use the Shift key when you press the key.

Press the Print Screen key (or Shift key+Print Screen key) now.

Go to the Print Screen document you just opened.

Click inside it to be sure the cursor is active in the document.

Right click.

Choose Paste.

You should see a picture of your completed claim in the Word window. You may need to complete the Print Screen function two or three times to display your entire claim form. (In other words, you may need to create a Print Screen of the top of your claim form, and paste that Print Screen in Word. Then, you may need to scroll in MedLook to display the bottom of your claim form, create a Print Screen of that portion of the form, and paste that Print Screen in to your Word document, too.) Your instructor must be able to view all fields for credit.

Save and close your Word document.


48 e0205502AS02B-54

Use the following information to complete a CMS-1500 form with MedLook for each of the following patients. Please note that you will complete 10 claims, and all 10 claims are worth a total of 100 points.

Patient Physician1. Bonnie Schmidt Donald Milford, MD2. Samuel Jones Greg Stephen, MD3. Rebecca Bloomquist James Hahns, MD4. Cathy Harrison Carolyn Hooper, MD5. Andy Cavello Matthew Grimm, MD6. Emma Smith Leslie Jones, MD7. Sally Tucker Scott Ludwig, MD8. Rocky Sanchez Sarah Duncan, MD9. Paula Higgins Dwight Harrison, MD

10. Amanda Tree Greg Stephen, MD

Assignment Pack 2

e0205502AS02B-54 49

Quiz 18 1. Bonnie SchmidtSchmidtMilford L18Q18 PIF

FRONT RANGE FAMILY CARE1800 Circle Court Yourtown, CO 80000 (970) 555-3344

______ Greg Stephen, MD NPI: 0267679942 __X___ Donald Milford, MD NPI: 0810998051 ______ Douglas Smart, MD NPI: 0144878804 Group NPI: 0881099885

Patient InformationName Bonnie Schmidt Date of Birth June 25, 1952 Address 1810 Bluegrass Drive Sex F Marital Status married City Springtown State CO ZIP 80002Home Phone 970-555-9041 Work Phone 970-555-6001 Cell Phone E-mail address

Employment InformationName of Employer Kain Graphics Occupation graphic designer If Minor, Name of School

Insurance InformationPrimary Insurance Secondary InsuranceName Country Group Name CHAMPVA ID# 560001113 ID# 635 00 7213 Group# 208 Group# Address PO Box 324 Address 4500 Cherry Creek Drive South; Box 64 City Springtown City Denver State CO ZIP 80002 State CO ZIP 80222 Primary Insured Name Bonnie Secondary Insured Name Richard Schmidt Relation to Patient self Relation to Patient Spouse DOB same as above DOB Sept 15, 1952 Employer Kain Graphics Employer USAF I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Bonnie Schmidt Signature of patient (or parent of minor child)


Richard Schmidt Signature of patient (or parent of minor child)

Physician signature: Donald Milford, MD SSN: 300-03-0303 EIN 66-6000600 Participating Provider for: TRICARE, CHAMPVA, Country Group and Blue Cross

Date of Service 5/10/XX Diagnosis Procedure Charge727.1 Bunionette Consult for Sarah Duncan, MD NPI: 0203048901

New Patient Level II 99242 $57.00

Today’s Charge $57.00 Payment $0.00 Amount Due $57.00


50 e0205502AS02B-54

Quiz 18 2. Samuel Jones

JonesStephen L18Q18 PIF

FRONT RANGE FAMILY CARE 1800 Circle Court Yourtown, CO 80000 (970) 555-3344

__X___ Greg Stephen, MD NPI: 0267679942 _______ Donald Milford, MD NPI: 0810998051 _______ Douglas Smart, MD NPI: 0144878804 Group NPI: 0881099885

Patient Information Name Samuel Jones Date of Birth May 19, 1972 Address 3 HWY South Sex M Marital Status Divorced City Anytown State CO ZIP 80000 Home Phone (970) 555-1313 Work Phone Cell Phone E-mail address

Employment Information Name of Employer Green Finger Nursery If Minor, Name of School full-time student

Insurance Information Primary Insurance Secondary Insurance Name Blue Cross of Iowa Name none ID# 666 00 6663 ID# Group# VE001 Group# Address PO Box 1677 Address City Sioux City City State IA ZIP 51102 State ZIP Primary Insured Name self Secondary Insured Name Relation to Patient self Relation to Patient DOB DOB Employer Green Finger Nursery Employer I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Samuel Jones Signature of patient (or parent of minor child)



Physician signature: Greg Stephen MD SSN: 700-07-0007 EIN 66-6000600 Participating Provider for: Blue Cross, HMO and Mutual Life Date of Service 3/13/XX Diagnosis Procedure Charge 845.00 Ankle sprain Established Patient, Level IV 99214 $85.00 X-ray, Ankle, 2-views 73600 $70.00 Today’s Charge $155.00 Payment $0.00 Amount Due $155.00

Assignment Pack 2

e0205502AS02B-54 51

Quiz 18 3. Rebecca Bloomquist

BloomquistHahns L18 Q18 PIF

James Hahns, MD 800 Medical Court Yourtown, CO 80000 (970) 555-2222

Patient Information Name Rebecca Bloomquist Date of Birth June 25, 1997 Address 409 Yorkshire Sex F Marital Status single City Yourtown State CO ZIP 80001 Home Phone 970-555-5875 Work Phone Cell Phone E-mail address [email protected]

Employment Information Name of Employer Occupation If Minor, Name of School Yourtown School full-time student

Insurance Information Primary Insurance Secondary Insurance Name Med Link HMO Name none ID# 521 00 900602 ID# Group# WBHMO Group# Address PO Box 560 Address City Yourtown City State CO ZIP 80001 State ZIP Primary Insured Name Dick Bloomquist Secondary Insured Name Relation to Patient father Relation to Patient DOB 03-10-1967 DOB Employer Wilton Bookstore Employer I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Dick Bloomquist Signature of patient (or parent of minor child)



Physician signature: James Hahns MD SSN: 900-00-9000 NPI: 0405674390 Participating Provider for: Medicaid and all private insurance Date of Service 2/24/XX Diagnosis Procedure Charge 959.7 Left knee injury 99212 Est. patient level 2 $50.00 Today’s Charge $50.00 Cash/Check $0.00 Balance $50.00


52 e0205502AS02B-54

Quiz 18 4. Cathy HarrisonHarrisonHooper L18Q18 PIF

Clinton Fangman, MD NPI: 010203321

Carolyn Hooper, MD NPI: 0188123456

Scott Ludwig, MD NPI: 0199654321

Stewart Center for Women Provider of Blue Cross 1200 Carol Lane EIN: 99-9009009

Yourtown, CO 80000 NPI: 0220332233(970) 555-1010

Patient InformationName Cathy Harrison Date of Birth August 9, 1967 Address 2419 Zendt Drive Sex Female Marital Status married City Anytown State CO ZIP 80000Home Phone (970) 555-2112 Work Phone (970) 555-1397 Cell Phone E-mail address

Employment InformationName of Employer Sandy’s Nails Occupation If Minor, Name of School

Insurance InformationPrimary Insurance Secondary InsuranceName Blue Cross of WY Name ID# 641000000 ID# Group# GE54002 Group# Address PO Box 456 Address City Casper City State WY ZIP 82002 State ZIP Primary Insured Name Tom Harrison Secondary Insured Name DOB 08-02-59 DOB Relation to Patient Spouse Relation to Patient Employer Front Range Auto Sales Employer I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Cathy Harrison Signature of patient (or parent of minor child)



Physician signature: Carolyn Hooper, MD

Date of Service 02/16/XX Diagnosis Procedure Charge 726.10 L. shoulder bursitis 99211 Est. patient level 1 $45.00


Assignment Pack 2

e0205502AS02B-54 53

Quiz 18 5. Andy CavelloCavelloGrimm L18 Q18

Patient InformationName Andy Cavello Date of Birth 1/15/97 Address 883 Claybasket Circle Sex M Marital Status City Anytown State CO ZIP 80001Home Phone (970) 555-8812 Work Phone Cell Phone E-mail address

Employment InformationName of Employer Student Status full time student

Insurance InformationPrimary Insurance Secondary InsuranceName Blue Cross of CO Name Cigna ID# 630 00 0099A ID# 119001031 Group# BM630 Group# 488C Address PO Box 76 Address 1212 Drake City Denver City Yourtown State CO ZIP 80217 State OH ZIP 01012 Primary Insured Name Mark Cavello Secondary Insured Name Cecelia Cavello DOB 7/6/68 DOB 10/9/70 Relation to Patient father Relation to Patient mother Employer Beaver Market Employer Advanced Engineering I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Mark Cavello Signature of patient (or parent of minor child)


Cecelia Cavello Signature of patient (or parent of minor child)

Physician signature: Matthew Grimm, MD

Date of Service 7/19/XX Diagnosis Procedure Charge 938 Swallowed foreign body 99202 New Patient, Office $75.00

Matthew Grimm, MD NPI: 0304851124 Provider of Blue Cross and Medicaid

David Rhodes, MD NPI: 0189218600 Provider of all private insurance

Springtown Clinic EIN: 86-80006001824 Park Avenue NPI: 0304455166

Springtown, CO 80000 970-555-1834


54 e0205502AS02B-54

Quiz 18 6. Emma SmithSmithJones L18 Q18

Dwight Harrison, MD Leslie Jones, MD Clifford Phillips, MD NPI: 0657490049 NPI: 0405891109 NPI: 0275695402 Provider for Medicaid and Western Workers Insurance

Provider for Medicare, Mutual Insurance and Blue Cross

Provider for Medicaid

Medical Care Center 100 South Main Yourtown, CO 80000 (970) 555-1111

Patient InformationName Emma Smith Date of Birth 1-30-30 Address 1410 Iris Drive Sex F Marital Status widowed City Mytown State CO ZIP 80001Home Phone 970-555-5843 Work Phone Cell Phone E-mail address

Employment InformationName of Employer retired Occupation Student Full-time Part-time

Insurance InformationPrimary Insurance Secondary InsuranceName Medicare Name none ID# 501 00 7319A ID# Group# NONE Group# Address 600 Grant Street Ste 600 Address City Denver City State CO ZIP 80203 State ZIP Primary Insured Name Emma Secondary Insured Name DOB DOB Relation to Patient Relation to Patient Employer Employer I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Emma Smith Signature of patient (or parent of minor child)



Physician signature: Leslie Jones MDGroup NPI: 0665544004 EIN 99-0000009 CLIA# CM8402

Date of Service 5/20/XX Diagnosis Procedure Charge 780.4 dizziness 99213 office visit $63.00

Assignment Pack 2

e0205502AS02B-54 55

Quiz 18 7. Sally TuckerTuckerLudwig L18 Q18

Clinton Fangman, MD NPI: 010203321 Carolyn Hooper, MD NPI: 0188123456Scott Ludwig, MD NPI: 0199654321

Stewart Center for Women EIN: 99-90090091200 Carol Lane NPI: 0220332233

Yourtown, CO 80000 Provider of Blue Cross (970) 555-1010

Patient InformationName Sally Tucker Date of Birth 11-26-60 Address 1801 Peterson Ct Sex female Marital Status married City Springtown State CO ZIP 80002Home Phone 970-555-3255 Work Phone 970-555-2969 Cell Phone E-mail address

Employment InformationName of Employer Allied Professions Occupation If Minor, Name of School

Insurance InformationPrimary Insurance Secondary InsuranceName Blue Cross of Iowa Name Mutual Life ID# 321 00 1010 ID# 402 00 4679 Group# BA1503 Group# LA4832 Address PO Box 1677 Address PO Box 911 City Sioux City City Denver State IA ZIP 51102 State CO ZIP 80111 Primary Insured Name Sally Secondary Insured Name Gregory Tucker DOB DOB 9-2-61 Relation to Patient self Relation to Patient spouse Employer Allied Professions Employer Lakeside Auto I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Sally Tucker Signature of patient (or parent of minor child)


Gregory Tucker Signature of patient (or parent of minor child)

Physician signature: Scott Ludwig, MD

Date of Service 4/1/XX Diagnosis Procedure Charge V72.31 GYN exam 99202 Office visit $75.00 81000 urinalysis $10.00

Total $85.00 Copayment $0.00 Balance Due $85.00


56 e0205502AS02B-54

Quiz 18 8. Rocky SanchezSanchezDuncan L18 Q18

Sarah Duncan, MD SSN: 333-33-00031414 Swallow Street NPI: 0203048901 Yourtown, CO 80000

(970) 555-1514Participating provider for Blue Cross, Mutual Life and Medicare

Patient InformationName Rocky Sanchez Date of Birth 8-21-27 Address 2621 Kings Ct Sex male Marital Status married City Yourtown State CO ZIP 80000Home Phone 970-555-1643 Work Phone Cell Phone E-mail address

Employment InformationName of Employer retired Occupation Student Full-time Part-time

Insurance InformationPrimary Insurance Secondary InsuranceName Medicare Name none ID# 325001926A ID# Group# Group# Address 600 Grant Street Ste 600 Address City Denver City State CO ZIP 80203 State ZIP Primary Insured Name self Secondary Insured Name DOB DOB Relation to Patient Relation to Patient Employer Employer I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Rocky Sanchez Signature of patient (or parent of minor child)



Physician signature: Sarah Duncan, MD

Date of Service 1010XX Diagnosis Procedure Charge 847.0 Neck sprain 99204 New patient level 4 $88.00


Assignment Pack 2

e0205502AS02B-54 57

Quiz 18 9. Paula HigginsHigginsHarris L18 Q18

Dwight Harrison, MD NPI: 0657490049 Provider for Medicaid and Western Workers Insurance

Leslie Jones, MD NPI: 0405891109 Provider for Medicare, Mutual Insurance and Blue Cross

Clifford Phillips, MD NPI: 0275695402 Provider for Medicaid

Medical Care Center 100 South Main

Yourtown, CO 80000(970) 555-1111

Patient InformationName Paula Higgins Date of Birth October 18, 1976 Address 2159 Wyndote Street Sex F Marital Status married City Yourtown State CO ZIP 80000Home Phone 970-555-1839 Work Phone 970-555-1613 Cell Phone E-mail address

Employment InformationName of Employer Dinger’s Pancake House Occupation Student Full time Part time

Insurance InformationPrimary Insurance Secondary InsuranceName none Name none ID# ID# Group# Group# Address Address City City State ZIP State ZIP Primary Insured Name Secondary Insured Name DOB DOB Relation to Patient Relation to Patient Employer Employer I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Paula Higgins Signature of patient (or parent of minor child)



Physician signature: Dwight Harrison, MD Group NPI: 0665544004 EIN 99-0000009

Date of Service 9/24/XX Diagnosis Procedure Charge Bronchial asthma 493.90 Office Visit Est Patient 99212 $50.00 Allergy shot 95120 $23.00


58 e0205502AS02B-54

Quiz 18 10. Amanda TreeTreeStephen L18 Q18

FRONT RANGE FAMILY CARE1800 Circle Court Yourtown, CO 80000 (970) 555-3344

__X___ Greg Stephen, MD NPI: 0267679942 ______ Donald Milford, MD NPI: 0810998051 ______ Douglas Smart, MD NPI: 0144878804 Group NPI: 0881099885

Patient InformationName Amanda Tree Date of Birth 7/10/2001 Address 35 Elm Street Sex F Marital Status single City Mytown State CO ZIP 80001Home Phone 970-555-3234 Work Phone Cell Phone E-mail address

Employment InformationName of Employer Address City State ZIP Phone Occupation Student Status X Full Time Part Time

Insurance InformationPrimary Insurance Secondary InsuranceName Mutual Life Name HMO ID# 542-32-5310 ID# 666-00-3519 Group# L558 Group# 683 Address PO Box 911 Address PO Box 17 City Denver City Mytown State CO ZIP 80111 State CO ZIP 80001 Primary Insured Name Sandy Tree Secondary Insured Name Cole Tree Relation to Patient mother Relation to Patient father DOB 02-13-1979 DOB 10-10-1977 Employer King’s Food Club Employer Atlantic Engineer I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Sandy Tree Signature of patient (or parent of minor child)


Cole Tree Signature of patient (or parent of minor child)

Physician signature: Greg Stephen MDSSN: 700-07-0007 EIN 66-6000600 Participating Provider for: Blue Cross, HMO and Mutual Life

Date of Service 12/19/XX Diagnosis Procedure Charge 599.0 UTI Established Patient, Level 3 99213 $63.00






NAME

ADDRESS

CITY STATE ZIP



e0205502AS02B-54 59

CB2


Attach your claim forms from MedLook to your Quiz Cover Sheet and submit to the school.


60 e0205502AS02B-54

Assignment Pack 2

e0205502AS02B-54 61

Mail-in Quiz 19

Select the best answer from the choices provided. Each item is worth 5 points.

1. Corrections reflecting changes on a previously submitted claim are termed _____. a. adjustments b. denialc. rejectedd. the clearinghouse

2. Before an insurance plan will begin to cover healthcare costs, the insured must pay any _____ required.a. copaymentsb. feesc. deductibled. premium

3. Richard visits Dr. Jones for a suspected sinus infection. On his way out, Richard pays $20 for this visit for his portion of the cost of the service. Richard pays this _____ each time he visits Dr. Jones’ office.a. copaymentb. feec. deductibled. premium

4. Suzie queries Mountain States Insurance regarding Daniel Sizemore’s unpaid claim. The representative for Mountain States Insurance tells her that Mr. Sizemore’s claim is in _____, or in review.a. denialb. rejectedc. suspensed. the clearinghouse


62 e0205502AS02B-54

5. Dr. Kuzzin is a participating provider in the Blue Cross Blue Shield program in his state. His billing specialist submitted a claim for $46 for a child who received a chickenpox vaccine. The corresponding EOB showed that Blue Cross Blue Shield will only reimburse Dr. Kuzzin $37, or Blue Cross Blue Shield’s _____, for this vaccine.a. deductibleb. allowable chargec. rejected charged. coinsurance amount

Assignment Pack 2

e0205502AS02B-54 63

Refer to the following EOB for Stacey Jones. Each item is worth 5 points.

6. Who is the member or subscriber of this insurance policy? _____a. Stacey Jonesb. Daniel Davis, MDc. Steven Jonesd. Acme, Inc.

7. What company does the subscriber work for? _____a. Mountain States Insuranceb. Acme, Inc.c. Daniel Davis, MDd. The information is not provided.


64 e0205502AS02B-54

8. Who was sent the $47.52 from the insurance company? _____a. Stacey Jonesb. Daniel Davis, MDc. Steven Jonesd. Acme, Inc.

9. What was the total amount not covered (disallowed) by the insurance company? _____ a. $15.48b. $47.52c. $35.48d. $20.00

10. If the patient has not already paid the copay, how much does she owe on this claim? _____a. $15.48b. $47.52c. $35.48d. $20.00

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e0205502AS02B-54 65

Refer to the following EOB for Joann Smith. Each item is worth 5 points.

EXPLANATION OF BENEFITSIf you have a question, please call your Healthy Choice Insurance

Customer Team at (555) 555-5555

Healthy Choice Insurance Claim #0000123 of Colorado Date 3-11-XX

Patient Employee/Subscriber Group Name Group Number Member Number

Joann Smith Martin Smith General Electric 5745-01 123-45-6789

Summary of Payment

Provider Maria Barns, MD NPI 2233664412

Total Amount Paid By Paid By SubscriberCharged Other Plan Your Plan Responsibility

$180.00 $0.00 $142.00 $20.00

Procedure Date of Amount Allowed Not Deductible Co-Insurance Reason AmountCode Service Charged Amount Covered Co-Payments Codes Paid

99214 0301XX $120.00 $110.00 $10.00 $0.00 $20.00 59/38 $90.0088150 0301XX $ 60.00 $52.00 $ 8.00 $0.00 $0.00 59/38 $52.00

Reason Codes:

(38) Co-insurance and co-payments are patient responsibility. (59) Contractual benefit. Patient is not responsible for non-covered charge(s).

Totals $180.00 $162.00 $18.00 $0.00 $20.00 $142.00

11. What is the provider’s NPI? _____a. 2233664412b. 5745-01c. 123-45-6789d. 0000123


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12. How much of this claim is the patient responsible for? _____a. $142.00b. $18.00c. $20.00d. $0.00

13. How much did Healthy Choice Insurance reimburse Maria Barns, MD? _____a. $142.00b. $162.00c. $18.00d. $0.00

14. What was the amount the insurance company allowed for procedure 99214? _____a. $120.00b. $180.00c. $110.00d. $162.00

15. What is the numerical code that explains that the patient is not responsible for noncovered charges? _____a. 38b. 59c. 59/38d. The patient is responsible for all charges.

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e0205502AS02B-54 67

Refer to the following EOB for Daniel Jones. Each item is worth 5 points.

EXPLANATION OF BENEFITSIf you have a question, please call your Healthy Choice Insurance

Customer Team at (555) 555-5555

Healthy Choice Insurance Claim #0000123 of Colorado Date 3-1-XX

Patient Employee/Subscriber Group Name Group Number Member Number

Daniel Jones Daniel Jones Howard Johnson 5584-03 987-65-4321

Summary of Payment

Provider Maria Barns, MD NPI 2233664412

Total Amount Paid By Paid By SubscriberCharged Other Plan Your Plan Responsibility

$195.00 $0.00 $172.00 $23.00

Procedure Date of Amount Allowed Not Deductible Co-Insurance Reason AmountCode Service Charged Amount Covered Co-Payments Codes Paid

45330 02/21/XX $195.00 $195.00 $23.00 37 $172.00

Reason Codes:

With this payment, patient has met$100.00 of the $100.00 individualdeductible for this plan.

(37) Patient has an annual deductible with this plan. Patient is responsible for amount applied to deductible.

Totals $195.00 $195.00 $23.00 $172.00

16. What is the amount applied to the patient’s deductible? _____a. $23.00b. $172.00c. $37.00d. No amount was applied to the deductible.


68 e0205502AS02B-54

17. What is the patient’s annual deductible? _____a. $200.00b. $195.00c. $100.00d. The patient doesn’t have a deductible.

18. What is the member/policy number listed on the EOB? _____a. Howard Johnsonb. 5584.03c. 2233664412d. 987-65-4321

19. What was the amount paid by another insurance company? _____a. $23.00b. $172.00c. $195.00d. $0.00

20. How much will Healthy Choice Insurance send to Maria Barns, MD for this claim? _____a. $172.00b. $195.00c. $23.00d. $0.00

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e0205502AS02B-54 69

Mail-in Quiz 20

Part 1

Questions 1 through 10 are each worth 2 points. Complete items 1 through 10 based on the following scenario:

Mary Wilson and Fred Taft both receive insurance from their employers. Mary’s birthday is April 27, 1966, and Fred’s is August 30, 1957. Fred and Mary are divorced; neither has remarried. Fred is the custodial parent of their child, John. Dr. Hobit provides medical services for John Taft on 09/17/XX. No payments were made at the time of service. Dr. Hobit does not accept assignment for either insurance.

1. The full name of the patient is ____________.

2. The full name of the primary insured is ____________.

3. The full name of the secondary insured is ____________.

4. When billing the secondary insurance, a copy of the primary insurance ____________ will need to be attached to the secondary claim.

5. There is a remainder of $20.00 after both insurances have paid. Can the medical biller bill the patient for the $20.00? ____________

6. Would a write-off amount be listed on a claims log for this claim? _________

7. In what column on a claims log would the reimbursement from the insurance company be recorded? ____________

8. If the date that the primary insurance claim is filed is 09/18/XX, the follow-up date would be ____________.

9. Does this patient receive a refund check? ____________

10. John Taft received medical services from Dr. Hobit on _________________.


70 e0205502AS02B-54

Part 2

Complete items 11 through 20 based on the explanation of benefits for Rocky Sanchez on the pages that follow. Each question is worth 2 points.

EXPLANATION OF MEDICARE BENEFITS 10/28/XX

BENEFICIARY NAME PERFORMING SUPPLIER SERVICE PLACE - TYPE

PROCEDURE AMOUNT BILLED

AMOUNT APPROVED

SEE NOTE

DEDUCTIBLE COINSURANCE PAYMENT

M.I.C. NO. CONTROL NUMBER FROM MO-DAY

TO DAY-YR

CODE - MODIFIERS

R. SANCHEZ 850 10-10 10-XX 1 99204 80.00 68.20 56 13.64 54.56325-00-1926A 10-10 10-XX 1 99070 45.00 12.50 56 2.50 10.00

NOTE----------------------------------------- EXPLANATION ---------------------------------------------56 THIS IS THE CHARGE ALLOWED BASED UPON THE PREVAILING OR USUAL AND CUSTOMARY RATE.

11. The amount billed for procedure 99204 was $____________.

12. The amount approved for procedure 99204 was $____________.

13. The amount billed for procedure 99070 was $____________.

14. The amount approved for procedure 99070 was $____________.

15. The total amount of the claim is $____________.

16. The total amount of benefits paid by the insurance carrier for the patient is $____________.

17. The patient will be responsible for the coinsurance amount totaling $____________.

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e0205502AS02B-54 71

18. According to the note, $80.70 is the charge allowed based upon the prevailing or __________________ rate.

19. Assuming the patient didn’t pay anything at the time of service, the patient will be billed $____________ by the provider.

20. Since the provider accepts assignment from the insurance, she will write off $________.

Part 3

Using the original encounter information and the explanation of benefits, fill out secondary insurance claim forms for:

● Kristy Arnold ● Sally Tucker ● Amanda Tree

For this Quiz you will NOT use the MedLook software. You may print or type your CMS-1500 forms. You do not need to attach the primary insurance EOBs to these secondary forms when you submit this assignment to the school. We encourage you to send this Quiz by e-mail. Simply contact your instructor by phone or e-mail, and request a PDF claim form. A blank PDF claim will be e-mailed to you to complete the claim forms. This portion of your Quiz is worth 60 points.


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Part 3—Original Encounter Form for Kristy ArnoldArnoldMilford L20 Q20 PIF

FRONT RANGE FAMILY CARE1800 Circle CourtYoungstown, CO 80001(970) 555-3344

______ Greg Stephen, MD NPI: 0267679942__X___ Donald Milford, MD NPI: 0810998051______ Douglas Smart, MD NPI: 0144878804

Group NPI: 0881099885

Patient InformationName Kristy Arnold Date of Birth April 7, 2001 Address 3519 Habit Rd Sex F Marital Status single City Youngstown State CO ZIP 80001Home Phone 970-555-8838 Work Phone Cell Phone E-mail address

Employment InformationName of Employer Occupation Student Status full time student

Insurance InformationPrimary Insurance Secondary InsuranceName Blue Cross of OH Name Country Group ID# 811000924 ID# 73055 Group# J620 Group# 210B Address 3737 Sylvania Ave Address PO Box 37 City Toledo City Toledo State OH ZIP 43623-4422 State OH ZIP 43623 Primary Insured Name Barbara Arnold Secondary Insured Name Bill Arnold Relation to Patient mother Relation to Patient father DOB 01-10-1979 DOB 12-23-1980 Employer Governor Company Employer Star Construction I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Barbara Arnold Signature of patient (or parent of minor child)


Bill Arnold Signature of patient (or parent of minor child)

Physician signature: Donald Milford, MD SSN: 300-03-0303 EIN 66-6000600 Participating Provider for: TRICARE, CHAMPVA, Country Group and Blue Cross

Date of Service 03/13/XX Diagnosis Procedure Charge 845.00 Sprain Ankle 99215 Est Patient Office Visit $100.00 73600 Radiology $50.00


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Part 3—EOB for Kristy Arnold


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Part 3—Original Encounter Form for Sally TuckerTuckerLudwig L20 Q20

Clinton Fangman, MD Stewart Center for Women Provider of Blue Cross and Mutual LifeNPI: 010203321 1200 Carol Lane NPI: 0220332233

Yourtown, CO 80000 EIN: 99-9009009Carolyn Hooper, MD (970) 555-1010NPI: 0188123456

Scott Ludwig, MD NPI: 0199654321

Patient InformationName Sally Tucker Date of Birth 11-26-60 Address 1801 Peterson Ct Sex female Marital Status married City Springtown State CO ZIP 80002Home Phone (970) 555-3255 Work

Phone(970) 555-2969 Cell

Phone

E-mail address

Employment InformationName of Employer Allied Professions Occupation If Minor, Name of School

Insurance InformationPrimary Insurance Secondary InsuranceName Blue Cross of Iowa Name Mutual Life ID# 321 00 1010 ID# 402 00 4679 Group# BA1503 Group# LA4832 Address PO Box 1677 Address PO Box 911 City Sioux City City Denver State IA ZIP 51102 State CO ZIP 80111 Primary Insured Name Sally Secondary Insured Name Gregory Tucker DOB DOB 9-2-61 Relation to Patient self Relation to Patient spouse Employer Allied Professions Employer Lakeside Auto I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Sally Tucker Signature of patient (or parent of minor child)


Gregory Tucker Signature of patient (or parent of minor child)

Physician signature: Scott Ludwig, MD

Date of Service 4/1/XX Diagnosis Procedure Charge V72.31 GYN exam 99202 Office visit $75.00 81000 Urinalysis $10.00

Total $85.00 Copayment $85.00 Balance Due $0.00

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e0205502AS02B-54 75

Part 3—EOB for Sally Tucker

75.00 15.00 60.00 12.00 48.00

48.00

54.40

100.00

300.00

10.00 2.00 8.00 .80 6.40

TUCKER, SALLY

04/01.XX NEW VISIT

04/01/XX LABORATORY


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Part 3—Original Counter Form for Amanda TreeTreeStephen L20 Q20

FRONT RANGE FAMILY CARE 1800 Circle Court Yourtown, CO 80000 (970) 555-3344

X Greg Stephen, MD NPI: 0267679942 ______ Donald Milford, MD NPI: 0810998051 ______ Douglas Smart, MD NPI: 0144878804 Group NPI: 0881099885

Patient Information Name Amanda Tree Date of Birth 7/10/2001 Address 35 Elm Street Sex F Marital Status single City Mytown State CO ZIP 80001 Home Phone 970-555-3234 Work Phone Cell Phone E-mail address

Employment Information Name of Employer Address City State ZIP Phone Occupation Student Status X Full time Part time If minor, name of school

Insurance Information Primary Insurance Secondary Insurance Name Mutual Life Name HMO ID# 542-32-5310 ID# 666-00-3519 Group# L558 Group# 683 Address PO Box 911 Address PO Box 17 City Denver City Mytown State CO ZIP 80111 State CO ZIP 80001 Primary Insured Name Sandy Tree Secondary Insured Name Cole Tree Relation to Patient mother Relation to Patient father DOB 02-13-1979 DOB 10-10-1977 Employer King’s Food Club Employer Atlantic Engineer I authorize the release of any information including diagnosis and treatment. I authorize my insurance carrier to pay directly to the doctor any benefits otherwise payable to me.

Sandy Tree Signature of patient (or parent of minor child)


Cole Tree Signature of patient (or parent of minor child)

Physician signature: Greg Stephen MD SSN: 700-07-0007 EIN: 66-6000600 Participating Provider for: Blue Cross, HMO and Mutual Life Date of Service 9/14/XX Diagnosis Procedure Charge463 Tonsillitis 99212 Established Patient, Level 2 $50.00 86403 Rapid Strep $15.00 Today’s Charge $65.00 Payment $0.00 Amount Due $65.00

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e0205502AS02B-54 77

Part 3—EOB for Amanda Tree


78 e0205502AS02B-54

Assignment Pack 2

e0205502AS02B-54 79

Complete Secondary Billing for Part 3, Kristy ArnoldCMS 1500 BLANK FORM 1500














MM DD YY








SIGNED DATE SIGNED





MM DD YY MM DD YY







NPI 2.

NPI 3.

NPI 4.

NPI 5.

NPI 6.





SIGNED DATE

a. b. a. b.


80 e0205502AS02B-54

Assignment Pack 2

e0205502AS02B-54 81

Complete Secondary Billing for Part 3, Sally TuckerCMS 1500 BLANK FORM 1500














MM DD YY








SIGNED DATE SIGNED





MM DD YY MM DD YY







NPI 2.

NPI 3.

NPI 4.

NPI 5.

NPI 6.





SIGNED DATE

a. b. a. b.


82 e0205502AS02B-54

Assignment Pack 2

e0205502AS02B-54 83

Complete Secondary Billing for Part 3, Amanda TreeCMS 1500 BLANK FORM 1500














MM DD YY








SIGNED DATE SIGNED





MM DD YY MM DD YY







NPI 2.

NPI 3.

NPI 4.

NPI 5.

NPI 6.





SIGNED DATE

a. b. a. b.


84 e0205502AS02B-54





NAME

ADDRESS

CITY STATE ZIP



e0205502AS02B-54 85

CB2


Part 1

1. ___________________________

2. ___________________________

3. ___________________________

4. ___________________________

5. ___________________________

Transfer your answers for Part 1 and Part 2 to this Answer Sheet. Then staple your completed secondary claim forms to this sheet.


86 e0205502AS02B-54

6. ___________________________

7. ___________________________

8. ___________________________

9. ___________________________

10. ___________________________

Part 2

11. ___________________________

12. ___________________________

13. ___________________________

14. ___________________________

15. ___________________________

16. ___________________________

17. ___________________________

18. ___________________________

19. ___________________________

20. ___________________________

Part 3—Submit with your completed secondary claim forms.

student assignment pack 2

Documents