please help with homework. Fill out the claims process worksheet and then the CMS 1500 form

##################>### ######################################################### #a ########################bjbj#################### ###8"##xJ\\xJ\\G#######_################################################## ################|#######|###!######!######!######!######! ###################"#######"#######"##8###@"######\\"##,####"######J######" ######"######"######"######"###########################J######/J######/J######/J######/J######/J######/J##$###L#####O#####SJ####### ###############! #########################################################SJ##############! ######!######"##############"##H###hJ######'######'######'#########j###! ######"######!######"######J##############'#############################################################J##############'######'#####6############################################## ###############################8######"##########P#############P$ ##L###7###############J######~J##0###J######7##### P######$##### P##$###8###################################################################### 8## ### P##############! ######9##p#################'############################################## ###########################SJ######SJ######################################b& ##########################################################J############## ######################################################## ######################################## ######## P######################################################################### ####################################################|###> ## ##:######### ################################################################################ ################################################################################ ################################################################################ ################################################################################ ################################################################################ #######################Claims Process: Collection Claim Data Part A: Read the following scenario:Mrs. Jane Sample (DOB 12/22/1967) called her primary care providers office and scheduled an appointment with Dr. Billings for Monday, October 22nd, 2015. She requested the appointment because she had a cough and some congestion as well as wheezing and a fever off and on for about three days prior. Upon registration, she informed the front desk that she had new insurance effective October 1, 2015. The insurance card was scanned and the following information was verified:Name: Jane SampleDOB 12/22/1967Address: 211 First Lane Houston, TX 77398Phone Number: (555) 727-5555Insurance Subscriber: John Sample DOB: 5/25/1965The doctor examined Mrs. Sample and felt that due to the wheezing, a chest X-ray was needed to determine if pneumonia was present. This patient has had a history of pneumonia, so it was medically necessary to evaluate the present signs and symptoms. The chest X-ray did reveal left lobe pneumonia.Mrs. Sample was given prescriptions for Erythromycin 500mg three times daily, Prednisone 5mg once daily, and Tessalon Pearls as needed for cough every four hours.Dr. Billings filled out the encounter form with the following information:Office Visit level of service: 99214 Charges: 150.00Chest xray: 71020 Charges: 125.00Diagnosis: Left Lower Lobe Pneumonia J18.1Ralph Billings MD777 Smith AvenueHouston, TX 77398Phone (555) 555-5555NPI: 1234567891 Part B: Mrs. Sample indicated that her insurance was new as of October 1st. Looking at the card below, please answer the following:Who is the subscriberWhat is the group number? What is the Identification number? What is the type of Taylor plan? What is the claims address? What is the copay listed for PCP? # Part C: Collecting accurate claims data ensures the likelihood of creating a clean claim. Using the information in the scenario in Part A, open the CMS_1500_Claim_Form and fill in the following fields of the 1500 claim form: Sections 1-11Section 21Section 24: lines 1 and 2Section 28Section 33####Claims Process WorksheetHCS/182 Version 2## PAGE \\* MERGEFORMAT #1### ################################################################################ ################################################################################ ################################################################################ ################################################################################ #############################%###'###(###)###*###2###O###P########## ### ### ### ##% ##* ##4 ##? ##M ##O ## ## ##. ##X ##] ##g ##z ## ## ## ## ## ## ## ################## ## ################## ## ##h #`#mH #sH ####h6C #mH #sH ####h ##h #mH #sH ## #hN^##hu####hu####hoJ####h\\ ####hoJ##hoJ#H*###h ####h #5#mH #sH ###h6C ##h#@^#mH #sH ####h6C ##h#0#5#\\#mH #sH ####h6C ##h##CJ##^J#####h6C ##hf:#CJ##^J#####hp? 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"";##v;#K.#### v [#+Ud_ea ## ( L9$ I] {CPd7Kn###Q? ###J#)\\ ? #`398l_I#[WztN ##.SFl)#m##j4# 4 ||# Fw]| _C#qBqIn ?#Vd68|0#7f97ati=w#ie#:@M4#W\\7ot: >G#! g)S^zM#fA#aw5k#/#>}_s#/N####o T\\| o_:t@>}u>V#3fPH#WN ##TR1e####:DF#0`:g#*Uk(Y$#G eYjqFGTVi7S'#? ~L#+#]t! ##.0o\\_/^]v_##RX1Y #h 5 o4liyk_ # w#T7sFn zr##[###QD#####gN$)#YD|#X,#[##b'8T5jSq*5UMs.#P>/! wo:#Qp$N#L#5j###,\\p|_#? #v8#HL/I,#Z,###`X'76mwN65r##i#}{J(o# #{#n #n z#kW^J#w #+V#Go>{C#S\\9? O=U##c d|r #,U(P#LsSP!#O&M#o w f#+V'OA#f Sf [ .#;vd B+/kdEw^ {G%i O>eQ,Y{2x`=1`#*TW!#3g:F#%KwoK %Yt){VZ1j(*UGh 9%r sTRE### D#| igrQvU3'{K#.\\#3f###JM4i#^z+WH*V#:t(| ##Fe###L##x 6mbG#T,C%Y#Wn##9q#`#%?)"+.]48.yX##? u#N#p9;u#M~CreXz%@q#! )WAj T^#SxqC#x#$I d#2dL2\\zB #? m*gt:_QFO#sM:vK)W_M { ##kG g#U#vv"m Q,Y@ 44)SRZ5IC.]d#,X)S'O#N1#B ###m6##DtXz5+Yd\\xKSZ5g #p#Sf uvjUv#UTB L8uRL###JuW#>}PL#_)\\09r w_/o@e ]^A)]4[neSOs;}^#.\\~ )S-[6 #*D| 8#W^K;s#tBt#C#eDEE1x`rEbH>=s [:?*3f QDi7/m ! SL4i i i 0 gN ^:#2d`!} ###@U###G4hSR%OAx##2d o l |%#/_I&d}RbE+K##8@l##VFr8|03gS #9# #pu.y_Ni9u!i> ? #G#G PjjP P Z#+}}w# /_& P#O# "(XQ#'.U%Ouy@A#bp6V*:1! +.DH#x#Sk#j5N|*t#`NQ_/ (n;RqIVd'#I#n###1#UN##R#P}3 ux5'Of uW@ #D^[###C.]3\\jrgc s'kfY:K-[J*1e#zI#'#}zOd ##.\\ 5# Leave blank Signature on file 38-5555555 Ralph Billings MD 10/22/2015 12456 25.00 10/22/12015 Clear Form BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BY APPLICABLE PROGRAMS. NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties. REFERS TO GOVERNMENT PROGRAMS ONLY MEDICARE AND CHAMPUS PAYMENTS: A patient's signature requests that payment be made and authorizes release of any information necessary to process the claim and certifies that the information provided in Blocks 1 through 12 is true, accurate and complete. In the case of a Medicare claim, the patient's signature authorizes any entity to release to Medicare medical and nonmedical information, including employment status, and whether the person has employer group health insurance, liability, no-fault, worker's compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made. See 42 CFR 411.24(a). If item 9 is completed, the patient's signature authorizes release of the information to the health plan or agency shown. In Medicare assigned or CHAMPUS participation cases, the physician agrees to accept the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary as the full charge, and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary if this is less than the charge submitted. CHAMPUS is not a health insurance program but makes payment for health benefits provided through certain affiliations with the Uniformed Services. Information on the patient's sponsor should be provided in those items captioned in \"Insured\"; i.e., items 1a, 4, 6, 7, 9, and 11. BLACK LUNG AND FECA CLAIMS The provider agrees to accept the amount paid by the Government as payment in full. See Black Lung and FECA instructions regarding required procedure and diagnosis coding systems. SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE, CHAMPUS, FECA AND BLACK LUNG) I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me or were furnished incident to my professional service by my employee under my immediate personal supervision, except as otherwise expressly permitted by Medicare or CHAMPUS regulations. For services to be considered as \"incident\" to a physician's professional service, 1) they must be rendered under the physician's immediate personal supervision by his/her employee, 2) they must be an integral, although incidental part of a covered physician's service, 3) they must be of kinds commonly furnished in physician's offices, and 4) the services of nonphysicians must be included on the physician's bills. For CHAMPUS claims<>