Directions with Performance Evaluation Checklist Study the EOB form in Workbook Figure 13-1, then calculate various figures and answer the following questions. 1st Attempt 2nd Attempt 3rd Attempt Gather materials (equipment and supplies) listed under Conditions. 1. How many patients' payment information is included on this EOB? 2. For patient Bradley Capell: What are the two dates procedures were performed? and 3. What was the total charge for both procedures? $ 4. Subtract the total amount allowed for both procedures from the total amount charged and indicate the "write off" amount. $ 5. What is the total amount applied to the deductible for both procedures? $ 6. What was the total co-payment collected? $. 7. Subtract the total amount of the co-payment collected from the total amount allowed, then compare this amou with the total amount paid on Bradley Capell's claim; write this amount. $ 13 8. For patient Margaret Champion: What service is being billed for on this claim? - 9. What is the amount that will be written off the books? $ 4 10. What is the total amount paid on Margaret Champion's claim? Indicate the math to verify this amount TILL TIL 111 12 11 What is the total amount paid for both patients on this claims Complete within specified time Total points earned (To obtain a percentage score, divide the total points earned by the number of points possible) /35 Type here to each EXPLANATION OF BENEFITS BC Insurance Company PO Box 27894 Chicago, IL 95927-0004 Practon Medical Group, Inc. 4567 Broadway Avenue Woodland Hills, XY 12345-4700 Physician: Gerald M. Practon, MD Member: Yes Provider Number: 46278897XX Issue Date: Page: Check No: 10-31-XX 021820377 PROCEDURE NUMBER BILLED AMOUNT NOTES DATES OF SERVICE ALLOWED AMOUNT DEDUCTIBLE UNITS OF SERVICE PATENT NAME ID NUMBER CROUD NUMBER COPY AMOUNT PATIENT ACCT NUMBER CLAN NUVER AMOUNT Pup CAP 107 CAPELL BRADLEY 0716XX 52201 20.75 73.13 170.62 TOX 1000.00 2007 TOTAL 00000 NOTES: 2 Because the physician of other health care provider is a member of ABC insurance, the allowed amount is accepted as payment in tu The subscriber istosponsible only for deductibles, copayment amounts and noncovered items. $146.26 is the patient's copayment portion For questions regarding the above claim please call (800) 123-4567 CHAMPION CAPS OTXX MARGARET TOTAL NOTES Because the physican or other health care provides a b er of ABOnsurance the owed amount is accepted as payment The subscribers responsible only for deductes, copayment amounts and noncovered me $45.00 the patient's comment portion STATEMENT Directions with Performance Evaluation Checklist Study the EOB form in Workbook Figure 13-1, then calculate various figures and answer the following questions. 1st Attempt 2nd Attempt 3rd Attempt Gather materials (equipment and supplies) listed under Conditions. 1. How many patients' payment information is included on this EOB? 2. For patient Bradley Capell: What are the two dates procedures were performed? and 3. What was the total charge for both procedures? $ 4. Subtract the total amount allowed for both procedures from the total amount charged and indicate the "write off" amount. $ 5. What is the total amount applied to the deductible for both procedures? $ 6. What was the total co-payment collected? $. 7. Subtract the total amount of the co-payment collected from the total amount allowed, then compare this amou with the total amount paid on Bradley Capell's claim; write this amount. $ 13 8. For patient Margaret Champion: What service is being billed for on this claim? - 9. What is the amount that will be written off the books? $ 4 10. What is the total amount paid on Margaret Champion's claim? Indicate the math to verify this amount TILL TIL 111 12 11 What is the total amount paid for both patients on this claims Complete within specified time Total points earned (To obtain a percentage score, divide the total points earned by the number of points possible) /35 Type here to each EXPLANATION OF BENEFITS BC Insurance Company PO Box 27894 Chicago, IL 95927-0004 Practon Medical Group, Inc. 4567 Broadway Avenue Woodland Hills, XY 12345-4700 Physician: Gerald M. Practon, MD Member: Yes Provider Number: 46278897XX Issue Date: Page: Check No: 10-31-XX 021820377 PROCEDURE NUMBER BILLED AMOUNT NOTES DATES OF SERVICE ALLOWED AMOUNT DEDUCTIBLE UNITS OF SERVICE PATENT NAME ID NUMBER CROUD NUMBER COPY AMOUNT PATIENT ACCT NUMBER CLAN NUVER AMOUNT Pup CAP 107 CAPELL BRADLEY 0716XX 52201 20.75 73.13 170.62 TOX 1000.00 2007 TOTAL 00000 NOTES: 2 Because the physician of other health care provider is a member of ABC insurance, the allowed amount is accepted as payment in tu The subscriber istosponsible only for deductibles, copayment amounts and noncovered items. $146.26 is the patient's copayment portion For questions regarding the above claim please call (800) 123-4567 CHAMPION CAPS OTXX MARGARET TOTAL NOTES Because the physican or other health care provides a b er of ABOnsurance the owed amount is accepted as payment The subscribers responsible only for deductes, copayment amounts and noncovered me $45.00 the patient's comment portion STATEMENT
