Order Description

 

 

Part I: Encounter forms
Encounter forms are used to generate insurance claims. They have patient identification
information, the date of service, and abbreviated diagnosis and procedure codes. The provider will check or circle the appropriate codes on the encounter form, and the insurance specialist enters the data (office charge, amount paid by the patient, and the total due).

Review the encounter form for JOHN SMITH which is located in “Course Resources”. Answer the following questions in a Word document:

1. During processing of the encounter form (to generate the claim), the billing specialist notices that the provider entered a check mark in front of the procedure, “Hemoccult Stool,” and a check mark in front of the diagnosis, “Gout.” Because medical necessity requires the diagnosis selected to justify the procedure performed, what should the Billing specialist do next?

2. The provider will accept whatever the payer determines is the allowed fee as payment in full.
Should the provider enter a check mark in the YES box for “ACCEPT ASSIGNMENT” on the
CMS1500? What is the ITEM NUMBER(s) of the section of the CMS 1500 form that the patient signs to authorize payment to the provider?

3. Refer to the CMS-1500 claim form found in your text. Which block on this form would contain an entry based on information contained in the encounter form section “DATE SYMPTOMS APPEARED, INCEPTION OF PREGNANCY, OR ACCIDENT OCCURRED”?

Part II: Explanation of Benefits
The patient receives an explanation of benefits (EOB) when the claims adjudication process is
finalized. Payment will be either denied or approved. The EOB contains information about what
was paid by the insurance company and any amount that the patient is responsible for. Although it is the patient’s responsibility to review the claim for errors, they often contact the office for assistance if they do find any. It is very important that the billing is done properly to avoid errors and non-payment.

Review the explanation of benefit forms for Mary Smith located in “DOC SHARING”.
In a Word document, answer the following:

1. What was the total amount that The Keystone Plan was charged for Mary S. Patient’s services on 05/04/2010?
2. How much has Mary S. Patient paid out of pocket year to date? (Assume that the deductible has been paid in full)
3. What is Mary S. Patient’s MEMBER ID number?
4. What was the total allowed amount by the insurance company for Mary S. Patient’s services on 05/04/2010?
5. What is Mary S. Patient’s annual medical/surgical deductible, according to the EOB?

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