Title: Activity: (CU3 M1) Practice Claim Form
Course: SkillsCom CRS 110 14.0 > Section: Credit Unit 3 Module 1

Instructions:

This Activity is a case study for a patient named Ricardo B Dementia.  See if you can complete this Medicaid claim form for this patient.

NOTE: This is your first time filling out one of these forms and as such you don't know what you don't know until you start doing it and have questions. Once you feel like you have it completed to the best of your ability, email your Content Expert a copy and ask them any questions that came up that you were unsure of. Consider this a Practice Run….. This is NOT graded.

To email your Content Expert a copy of your completed form, you must follow these steps exactly.

- Once you have completed the document, click "CNTL P"
- Change the destination to: "Save as PDF"
- Click "Save"
- Enter the file name: Dementia
- Save it to your Desktop for easy access.
- If you do not follow these steps exactly, your form will not save the information that you have embedded into it.

Assignment:

1. Open and complete the following document:

- New CMS 1500 (PDF)

2. Using the following information, complete the fillable CMS 1500 form.

Patient Ricardo B Dementia, born June 17, 1961, lives at 1662 NW Courier St, Albany, OR 97321, 541-967-2265.  Billing -  UBSCREWED Insurance Co, Box 1662 Portland St., Portland, OR 97223, 503-266-6396.  This is an employer sponsored health plan.  His ID# is 562-63-5598.  Employer is Albany Dry Goods and the plan is in his wife’s name.  Bonita Dementia, born June 14, 1961, same address.  Her group number is UB162259.  The physician is Jackson Tippet, MD.  He works for the Albany Clinic, 8552 W. Moreland St, Albany, OR 97321.  Dr. Tippet’s NPI is 4775223162 and the clinic’s group NPI is 4775226254, their phone number is 541-926-1147.

Ricardo came to the clinic on August 14, 2016 for a complaint of hemorrhoids (K64.8) that have become painful and occasional rectal bleeding with BRBPR (K62.5).  Dr. Tippet performed level IV Office Visit (99214).

3. If you wish to review how to fill out the CMS 1500 form, consult the following references:

- Medicare Claims Processing Manual (PDF)
  - The "How To" instruction manual
- Medicare and You (PDF)
  - This is a handbook published by the United States government each year that outlines the Medicare plan.  Review it for information on how how Medicare is structured.
- "How to Use the Searchable Physician Fee Schedule (MPFS)" (PDF)
  - Coding and reimbursement specialists should be familiar with this document, which helps explain the different Medicare Physician Fee Schedules.
- Medicare Provider Fee Schedule Lookup Tool (Webpage)
  - Use this website to get the current allowable charge. The scenario provided below does not use account numbers and it does accept assignment.

- One additional note: OHP and Oregon Medicaid claims both use the “Medicaid” box in item 1 of your claim form.  Workers comp and other third party claims use the “other” box.