The objective of these exercises is to correctly complete workers’ compensation
ID: 2470463 • Letter: T
Question
The objective of these exercises is to correctly complete workers’ compensation claims, applying what you have learned in the chapter. Each case has two sections. The first section contains information about the patient, the insurance coverage, and the current medical condition. The second section is an encounter form for Valley Associates, PC.
If you are gaining experience by completing a paper CMS-1500 claim form, use the blank claim form supplied to you (from the back of the book or printed from the book’s Online Learning Center) and follow the billing notes on pages 255–256 to fill in the form by hand. Alternatively, the Online Learning Center provides an electronic CMS-1500 form that can be used to fill in and print claims using Adobe Reader. See The Interactive Simulated CMS-1500 Form in Appendix B at the back of this text for further instructions.
The following provider information, which is also available in the Medisoft database, should be used for Cases 12.1 and 12.2.
Provider Information
Name
Sarah Jamison, MD
Address
1400 West Center Street
Toledo, OH 43601-0213
Telephone
555-321-0987
Employer ID Number
07-2345678
NPI
5544882211
Assignment
Accepts
Signature
On File (1-1-2016)
Case 12.1
LO 12.1–12.4 From the Patient Information Form:
Name
Frank Puopolo
Sex
M
Birth Date
05/17/1969
Marital Status
M
Address
404 Belmont Place
Sandusky, OH 44870-8901
SSN
239-04-9372
Health Plan
CarePlus Workers’ Compensation
Insurance ID Number
2090462-37
Group Number
OH111
Employer
JV Trucking
Condition Related to:
Employment?
Yes
Auto Accident?
No
Other Accident?
No
Date of Current Illness, Injury, LMP
6/2/2016
Dates Patient Unable to Work
6/2/2016
Date of Hospitalization
6/2/2016
Explanation / Answer
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