Title: Competency Assessment: (CU3 M2) Complete Insurance Claim Forms
Course: SkillsCom CRS 110 14.0 > Section: Credit Unit 3 Module 2

Instructions:

The following case study is for patient Amanda Chin. Complete the claim form for this patient.

Assignment:

1. Review the following documents:

- Patient information sheet for Amanda Chin (patient) (PDF Download)
- Encounter Form for Amanda Chin (patient) (PDF Download)

2. Additional insurance information

- Deductible has been met
- Allowable = $150.00
- This insurance pays 80/20

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

- 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 33a.

4. Submit the completed document following these steps:

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

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