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  • HCR 203 Week 2 CMS-1500 Claim Form Worksheet

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


HCR 203 Week 2 CMS-1500 Claim Form Worksheet

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