Title: Competency Assessment: (CU3 M1) Complete Insurance Claim Forms
Course: SkillsCom CRS 110 14.0 > Section: Credit Unit 3 Module 1

Instructions:

The following case study is for patient Carter Doe.  Complete the claim form for this patient.

Assignment:

1. Review the following documents:

- Patient information sheet for Carter Doe (patient) (PDF Download)
- 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:

- Once you have completed the document, click "CNTL P"
- Change the destination to: "Save as PDF"
- Click "Save"
- Enter the file name: DOE
- 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.