Instructions:
The following case study is for patient Carter Doe. Complete the claim form for this patient.
Assignment:
1. Review the following documents:
Encounter Form for Carter Doe (patient) (PDF Download)
2. Open and complete the following document: CMS - 1500 claim form (PDF Download).
Jane Doe (parent) is the insurer and has an Insurance Group# of 1900000-MD10.
Use the online Medicare Provider Fee Schedule Lookup Tool (Webpage) to get the current allowable charge.
Use 42 17890908 EIN for Block 25.
The date in Block 31 should be 1 day after the last day of service listed on the claim.
Use X100X1000 as the facility NPI for Block 33a.
3. Submit the completed document following these steps:
NOTE: If you do not follow these steps exactly, your form will not save the information that you have embedded into it.