ASSIGNMENT 14.2 COMPLETE A HEALTH INSURANCE CLAIM FORM FOR A PRIVATE CASE Performance Objective Complete a health insurance claim form Task: Condition Standards: Use Merry M. McLean's patient record, one health insurance claim form, a computer or pen Claim Productivity Measurement Time: minutes Accuracy, Directions: (Note: The time element and accuracy criteria may be given by your instructor.) 1. Complete the Health Insurance Claim Form, using NUCC guidelines, and send the form to the Prudential Insurance Company for Mrs. Merry M. McLean by referring to the patient record. Date the claim June 15 of the current year. Record on the financial account record/statement when you have billed the insurance company. 2. A Performance Evaluation Checklist may be reproduced from the "Instruction Guide to the Workbook" in a section before Chapter 1 if your instructor wishes you to submit it to assist with scoring and comments. After the instructor has returned your work to you, either make the necessary corrections and place your work in a three-ring notebook for future reference, or, if you received a high score, place it in your portfolio for reference when applying for a job. COLLEGE CLINIC 4567 Adland Hills, XY12345-0001 Fax: (555) 487-8976 NPL 3664021CC PATIENT INFORMATION: Merry M. Mcl.com INSURANCE INFORMATION: Primary Pradial Inc Addres Woodland Hills, XY 12345 Date of Bir Telephone Social Security Occupation 1555) 486-139 020314 SECRETARY Porter Company 5621 Wilshire Blvd Merck XY 12346 (555) 664-9023 Policy Number Group Number Subscriber Secondary Harry L. McLean None Mek, XY 12346 Harry L. McLea DIAGNOSIS INFORMATION 1. N3201 Vesicle filterwise specified 5 Urinary incontinence, umpecified A PROCEDURE INFORMATION Descriptio 1. Office visit, new patien Date Code Charge 006/20XX 7092 030XX $1000 8.00 3. 06/10/20 53000 167.05 05120X 73.00 5. Repair spicginal f 05/17/20XX 51900 119682 05/18/20 N/C 7. Hav 05/19/20 NC 05/20/20 NIC 9. Hospital visit 05/21/200X 99024 NC 10. Discharge 09/22/2003 99024 N/C 11. Follow-up office vis X 99034 NC NOTES Referred by: Finder Fine, MD, 5000 Wilshire Blvd, Monk, XY 12346 NPL 73027175XX Treng MD: Gene UMD NPL25678831XX Place of service: College Clinic for 56-5/10,65 College Hospital for 16-5/22 4500 ad A. Woodland Hills, XY 12345 NPL X950731067