03 Feb full. Should the provider

1. During processing of the encounter form (to generate the claim), the billing specialist notices that the provider entered a checkmark in front of the procedure, “Hemocult Stool,” and a check mark in front of the diagnosis, “Gout.” Because medical necessity requires the diagnosis selected to justify the procedure performed, what should the Billing specialist do next? 2. . The provider will accept whatever the payer determines is the allowed fee as payment in full. Should the provider enter a check mark in the YES box for “ACCEPT ASSIGNMENT” on the CMS1500? What is the ITEM NUMBER(s) of the section of the CMS 1500 form that the patient signs to authorize payment to the provider? 3. Refer to the CMS-1500 claim form found in your text. Which block on this form would contain an entry based on information contained in the encounter form section “DATE SYMPTOMS APPEARED, INCEPTION OF PREGNANCY, OR ACCIDENT OCCURRED”? Part B: Explanation of Benefits The patient receives an explanation of benefits (EOB) when the claims adjudication process is finalized. Payment will be either denied or approved. The EOB contains information about what was paid by the insurance company and any amount that the patient is responsible for. Although it is the patient’s responsibility to review the claim for errors, they often contact the office for assistance if they do find any. It is very important that the billing is done properly to avoid errors and non-payment. Review the explanation of benefit forms for Mary Smithlocated in Course Documents. In a Word document, answer the following: 1. What was the total amount that The Keystone Plan was charged for Mary S. Patient’s services on 05/04/2010? 2. How much has Mary S. Patient paid out of pocket year to date? (Assume that the deductible has been paid in full) 3. What is Mary S. Patient’s MEMBER ID number? 4. What was the total allowed amount by the insurance company for Mary S. Patient’s services on 05/04/2010? 5. What is Mary S. Patient’s annual medical/surgical deductible, according to the EOB? Part C: Essay Questions 1. Discuss the differences and similarities of the various third-party insurance plans. 2. Discuss the differences between Medicare and Medicaid. Be sure to include information regarding federal and state laws governing the two diverse types of insurance, qualifications, and limitations of each program.

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