Claim control numbers are created by adding the eight digit date to the patient account number, as in PORCEJE0 01012016 A copayment of $15 is collected from each Oxford PPO patient at the time of the visit A copayment of $10 is collected for Oxford HMO The practice uses NDC as its clearinghouse to transmit claims The necessary data for the payer and the clearinghouse are stored in the programs databases Provider Information Billing Provider Valley Associates, PC NPI 1476543215 Address 1400 West Center Street Toledo, OH 43601 0213 Telephone 555 967 0303 Employer ID Number 16 1234567 Rendering Provider Christopher M Connolly, MD NPI 8877365552 Oxford PPO Provider Number 1011 Oxford HMO Provider Number 2567 Assignment Accepts Case From the Patient Information Form Name Kalpesh Shah Sex M Birth Date 01 21 2005 Assignment of Benefits Y Signature on File Y Primary Insurance Insured Raj Shah Patient Relationship to Insured Son Insureds Birth Date 02 16 1976 Insureds Sex M Insureds Address 1433 Third Avenue, Cleveland, OH 44101 1234 Insureds Employer Cleveland Savings Bank Insurance Policy Group Number G0904 Insurance Plan Program Name Oxford Freedom PPO Member ID 3302112090X Encounter Form See below Questions Are the subscriber and the patient the same person What is the code for the patients relationship to the insured What is the claim filing indicator code What amount is being billed on the claim What claim control number would you assign to the claim VALLEY ASSOCIATES, PC Christopher M Connolly, MD Internal Medicine 555 967 0303 NPI 8877365552 PATIENT NAME APPT DATE TIME 10 4 2018 Shah, Kalpesh 3 30 pm PATIENT NO 1 H61 23 cerumen in ear SHAHKALO 2 3 4 DESCRIPTION CPT FEE DESCRIPTION OFFICE VISITS PROCEDURES New Patient Diagnostic Anoscopy 46600 LI Problem Focused 99201 ECG Complete 93000 10060 99202 LII Expanded D, Abscess LIll Detailed 99203 Pap Smear 88150 LIV Comp Mod 99204 Removal of Cerumen V69210 63 17000 LV Comp High 99205 Removal 1 Lesion 17003 Established Patient Removal 2 14 Lesions 17004 99211 30Removal 15 Lesions LI Minimum LII Problem Focused 99212 Rhythm ECG w Report 93040 93041 LIII Expanded 99213 Rhythm ECG w Tracing LIV Detailed 99214 Sigmoidosco 45330 LV Co 9215 VALLEY ASSOCIATES, PC Christopher M Connolly, MD Internal Medicine 555 967 0303 NPI 8877365552 PATIENT NAME APPT DATE TIME 10 4 2018 Shah, Kalpesh 3 30 pm PATIENT NO 1 H61 23 cerumen in ear SHAHKALO 2 3 4 DESCRIPTION CPT FEE DESCRIPTION OFFICE VISITS PROCEDURES New Patient Diagnostic Anoscopy 46600 LI Problem Focused 99201 ECG Complete 93000 10060 99202 LII Expanded D, Abscess LIll Detailed 99203 Pap Smear 88150 LIV Comp Mod 99204 Removal of Cerumen V69210 63 17000 LV Comp High 99205 Removal 1 Lesion 17003 Established Patient Removal 2 14 Lesions 17004 99211 30Removal 15 Lesions LI Minimum LII Problem Focused 99212 Rhythm ECG w Report 93040 93041 LIII Expanded 99213 Rhythm ECG w Tracing LIV Detailed 99214 Sigmoidosco 45330 LV Co 9215

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Claim control numbers are created by adding the eight-digit date to the patient account number, as in PORCEJE0-01012016. A copayment of $15 is collected from

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Claim control numbers are created by adding the eight-digit date to the patient account number, as in PORCEJE0-01012016.
A copayment of $15 is collected from each Oxford PPO patient at the time of the visit. A copayment of $10 is collected for Oxford HMO.
The practice uses NDC as its clearinghouse to transmit claims.
The necessary data for the payer and the clearinghouse are stored in the programs databases.

Provider Information
Billing Provider	Valley Associates, PC NPI 1476543215
Address	1400 West Center Street Toledo, OH 43601-0213
Telephone	555-967-0303
Employer ID Number	16-1234567
Rendering Provider	Christopher M. Connolly, MD
NPI	8877365552
Oxford PPO Provider Number	1011
Oxford HMO Provider Number	2567
Assignment	Accepts

Case: From the Patient Information Form:

Name	Kalpesh Shah
Sex	M
Birth Date	01/21/2005
Assignment of Benefits	Y
Signature on File	Y


Primary Insurance
Insured	Raj Shah
Patient Relationship to Insured	Son
Insureds Birth Date	02/16/1976
Insureds Sex	M
Insureds Address	1433 Third Avenue, Cleveland, OH 44101-1234
Insureds Employer	Cleveland Savings Bank
Insurance Policy Group Number	G0904
Insurance Plan/ Program Name	Oxford Freedom PPO
Member ID	3302112090X
Encounter Form	See below.

Questions

Are the subscriber and the patient the same person?
What is the code for the patients relationship to the insured?
What is the claim filing indicator code?
What amount is being billed on the claim?
What claim control number would you assign to the claim?

VALLEY ASSOCIATES, PC Christopher M. Connolly, MD Internal Medicine 555-967-0303 NPI 8877365552 PATIENT NAME APPT. DATE/TIME 10/4/2018 Shah, Kalpesh 3:30 pm PATIENT NO 1. H61.23 cerumen in ear SHAHKALO 2. 3. 4. DESCRIPTION CPT | FEE | DESCRIPTION OFFICE VISITS PROCEDURES New Patient Diagnostic Anoscopy 46600 LI Problem Focused 99201 ECG Complete 93000 10060 99202 LII Expanded &D, Abscess LIll Detailed 99203 Pap Smear 88150 LIV Comp./Mod 99204 Removal of Cerumen V69210 63 17000 LV Comp./High 99205 Removal 1 Lesion 17003 Established Patient Removal 2-14 Lesions 17004 99211 30Removal 15+ Lesions LI Minimum LII Problem Focused 99212 Rhythm ECG w/Report 93040 93041 LIII Expanded 99213 Rhythm ECG w/Tracing LIV Detailed 99214 Sigmoidosco 45330 LV Co 9215 VALLEY ASSOCIATES, PC Christopher M. Connolly, MD Internal Medicine 555-967-0303 NPI 8877365552 PATIENT NAME APPT. DATE/TIME 10/4/2018 Shah, Kalpesh 3:30 pm PATIENT NO 1. H61.23 cerumen in ear SHAHKALO 2. 3. 4. DESCRIPTION CPT | FEE | DESCRIPTION OFFICE VISITS PROCEDURES New Patient Diagnostic Anoscopy 46600 LI Problem Focused 99201 ECG Complete 93000 10060 99202 LII Expanded &D, Abscess LIll Detailed 99203 Pap Smear 88150 LIV Comp./Mod 99204 Removal of Cerumen V69210 63 17000 LV Comp./High 99205 Removal 1 Lesion 17003 Established Patient Removal 2-14 Lesions 17004 99211 30Removal 15+ Lesions LI Minimum LII Problem Focused 99212 Rhythm ECG w/Report 93040 93041 LIII Expanded 99213 Rhythm ECG w/Tracing LIV Detailed 99214 Sigmoidosco 45330 LV Co 9215