HIMA_240_ASSIGNMENT_CMS_1500.docx

Sunil Adhikari
Compliance & Leadership

American Military University
HIMA 240
Instructor: Kris Hancke
Knowledge Activity: CMS 1500
All the answers are highlighted in red,
EHR Go Knowledge Activity: CMS 1500 (Baccalaureate) HBK1017.1 1

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1. Insurance type & Insured’s I.D. Number
a. Completely present on electronic claim
Insurance type: BCBS Gold Plus
Id: 000547819
b. Partially present or not clear on electronic claim
c. Not present on electronic claim
2. Patient’s name
Answer: Liu Huang
3. Patient Birth Date

Answer: 04/10/1961
4. Insured’s name
Answer: Huang, Liu
5. Patient’s address
Answer: 15168 Main Street, New York, NY,12345
6. Patient’s relationship to insured

Answer: Self

7. Insured’s address
8. Patient status
Answer: marital status: Married
Employment status: Employed
9. Other insured’s name

10. Is the patient’s condition related to (employment/auto accident/other accident)

Answer: The problem mentioned is Bursitis of Right shoulder, but the cause is not
clear.
11. Insured’s policy group or FECA number, date of birth, employer, plan name, benefit
plan name (if applicable)
Answer: Only partial information is provided
Date of birth: 04/10/1961
Plan name: BCBS Gold plus
Employer: Neil, Huang, and Simshich
12. Authorization release


13. Insured’s signature

14. Date of condition

15. First date of condition

16. Dates patient unable to work in current occupation

17. Name of referring physician, I.D. number of referring physician

18. Hospitalization dates related to current services

05/24/2018
19. N/A (Reserved for local use). Skip to next question.
20. Outside lab charges?

21. Diagnosis or nature of illness or injury

Answer : Shoulder pain
22. Medicaid resubmission code (if applicable)

23. Prior authorization number (if applicable)

24. Procedural codes for services rendered and related diagnostic code pointer
Answer : M 75.51
25. Federal tax I.D. number

26. Patient’s account number

Answer: MR177658

27. Accept assignment? Yes or No
Answer: It is not clear about the acceptance
For 28-30, see the Ledger Tab. Keep in mind that you are auditing the availability of the fields
themselves, and not the patient data, or lack thereof, entered in the fields.
28. Total charges

Answer: $250
29. Amount paid

30. Balance due

31. Signature of physician to be reimbursed

32. Name and address of facility where the services were rendered
Answer: Only central clinic is mentioned
33. Physicians, suppliers billing name, address, zip code, and phone number

34. List the items that were not completely present or were missing from the electronic
claim.
Answer: Following items were completely or partially missing from the electronic claim,
Insured’s address
Other insured name
Insured’s policy group or FECA number
Authorization release
Insured signature
First date of insurance
Dates patient was unable to work due to current condition
Name of referring physician
I.D number of physicians
Outside lab charges
Medicaid resubmission code
Federal tax ID number
Signature of physician to be reimbursed
Address of the facility where services were provided
Supplier’s billing name, address, and phone number
35. Of the missing or incomplete items, which do you think would be most likely to cause
this electronic claim to be rejected?
I think name and id of providing physician, facility name and address, Signature of
physician to be reimbursed, Authorization release and Insured signature are very
important. If these items are missing or incomplete the electronic claim can be rejected.
36. Do you think paper submission or electronic submission of the CMS 1500 billing form
would result in less errors? Explain your answer.

Answer: In my view, electronic submission of the CMS 1500 billing form would result in
less errors. When we do the fill the paper, many errors such as spelling, numbers can
occur unintentionally. When we do electronic submission system is more likely to detect
those errors. paper submission may causes misinterpretation due to handwriting, on the
receiving end, which may cause error in claim, but electronic submission will not have
those issues. Also, I it easy to read and understand electronic fillings than paper fillings.
Submit your work

Document your answers directly on this activity document as you complete the activity. When
you are finished, save this activity document to your device and upload this activity document
with your answers to your Learning Management System (LMS). If you have any questions about
submitting your work to your LMS, please contact your instructor.
References
Empire Blue Cross Blue Shield. (2003, June). Empire Blue Cross Blue Shield. Retrieved from Empire Blue
Cross Blue Shield Claim Form:
https://www.empireblue.com/provider/noapplication/f5/s1/t2/pw_b157015.pdf?
Medicare Learning Network. (2011). CMS 1500 At a Glance. Washington D.C.: CMS.

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Sunil Adhikari

Compliance & Leadership

All the answers are highlighted in red,

EHR Go Knowledge Activity: CMS 1500 (Baccalaureate) HBK1017.1 1

3. Patient Birth Date

6. Patient’s relationship to insured

EHR Go Knowledge Activity: CMS 1500 (Baccalaureate) HBK1017.1 2

9. Other insured’s name

10. Is the patient’s condition related to (employment/auto accident/other accident)

12. Authorization release

EHR Go Knowledge Activity: CMS 1500 (Baccalaureate) HBK1017.1 3

13. Insured’s signature

14. Date of condition

15. First date of condition

16. Dates patient unable to work in current occupation

17. Name of referring physician, I.D. number of referring physician

18. Hospitalization dates related to current services

19. N/A (Reserved for local use). Skip to next question.

20. Outside lab charges?

EHR Go Knowledge Activity: CMS 1500 (Baccalaureate) HBK1017.1 4

21. Diagnosis or nature of illness or injury

22. Medicaid resubmission code (if applicable)

23. Prior authorization number (if applicable)

25. Federal tax I.D. number

26. Patient’s account number

EHR Go Knowledge Activity: CMS 1500 (Baccalaureate) HBK1017.1 5

28. Total charges

29. Amount paid

30. Balance due

31. Signature of physician to be reimbursed

EHR Go Knowledge Activity: CMS 1500 (Baccalaureate) HBK1017.1 6

EHR Go Knowledge Activity: CMS 1500 (Baccalaureate) HBK1017.1 7

Submit your work

EHR Go Knowledge Activity: CMS 1500 (Baccalaureate) HBK1017.1 8

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