Below is a line from a remittance advice. Please answer the two questions below based on the following information:

POS Proc Billed Allowed DEDUCT COINS PROV PD

11 99203 169.00 169.00 69.00 20.00 80.00

What amount can be billed to the patient? ______________

What amount is paid by the insurance company? _______________

What is the name of the HIPAA electronic claim form for physicians? ______________

What is the name of the HIPAA electronic RA?