Title: Activity: (CU4 M2) Practice Insurance Claim Forms - Workers Compensation
Course: SkillsCom CRS 110 14.0 > Section: Credit Unit 4 Module 2

Instructions:

The following case study is for patient Noah Miller.  See if you can complete this claim form for this patient with workers' compensation coverage.

Assignment:

1. Review the following documents:

- Community Workers' Compensation: CMS Billing Tips (PDF)
- Patient information sheet for Noah Miller (PDF)
- Encounter Form for Noah Miller (PDF)

2. Open and complete the following document: CMS-1500 claim form (PDF)

- NOTE: Use 42 17890908  EIN for Block 25
- HINT: The date in Block 31 should be 1 day after the last day of service listed on the claim.
- NOTE: Use X100X1000 as the facility NPI for Block 32a
- NOTE: Use X100X1000 as the facility NPI for Block 33a

3. If  you have questions, contact your Content Expert and have a conversation.  Save it to your desktop so you can refer to it if you have questions.

- Once you have completed the document, click "CNTL P"
- Change the destination to: "Save as PDF"
- Click "Save"
- Enter the file name: Parker
- Save it to your Desktop for easy access.

NOTE: If you do not follow these steps exactly, your form will not save the information that you have embedded into it.