Required information Applying Your Knowledge Cate 81 Abstracting insurance Information Note: tra question will not be automatically graded it wir be sent to your instructor for review Based on the following notes, tu out the precertification form below for Deny Snowicz Encounter Date 05.04/2029 Patient Elizabeth R Sinowicz Date of Birth 08/02/1954 Address: 45 Maple Hill Road, Apt. 12-8Rangeley, MN 55655 Home Telephone 555-123-9887 Employer Argon Electric Company, 238 Industry Way, Rangeley, MN 55554 Work Telephone: 555-124-8754 Betty is on Medicare. She also has Insurance coverage through Argon Electric in the Horton PPO Her insurance Card shows her member number as 65 PO, no group number is shown Betty was referred to Dr Hank R. Ferrara, a Horizon participating ophtalmologist PN 349.00 for evaluation of her blutred and dimmed Vision Aer conducting an examination and taking the necessary restory De Ferrara diagnoses the patients condition as a cortical agereated cataract of the left eye that is close to mature ACD.10 CM H250121 Dr Ferrara decides to schedule Betty for sens extraction, the procedures ambulatory care surgery with same-day admission and discharge. The procedure will be done at Mischogle Hospital's Outpatients on 5/10/2020 Horton PPO requtres precertification for this procedure CPT 66984) PRECERTIFICATION FORM Insurance comes Certification for surgery and or acestion or Patient name Street address Citytrip Telephone Date of birth Subscriber name Employer Member no Gone Acting physican Provider no Hospitality Pinned procedure date Dugnas/symptoms Treatment procedure Estedeng of stay Required information Applying Your Knowledge Cate 81 Abstracting insurance Information Note: tra question will not be automatically graded it wir be sent to your instructor for review Based on the following notes, tu out the precertification form below for Deny Snowicz Encounter Date 05.04/2029 Patient Elizabeth R Sinowicz Date of Birth 08/02/1954 Address: 45 Maple Hill Road, Apt. 12-8Rangeley, MN 55655 Home Telephone 555-123-9887 Employer Argon Electric Company, 238 Industry Way, Rangeley, MN 55554 Work Telephone: 555-124-8754 Betty is on Medicare. She also has Insurance coverage through Argon Electric in the Horton PPO Her insurance Card shows her member number as 65 PO, no group number is shown Betty was referred to Dr Hank R. Ferrara, a Horizon participating ophtalmologist PN 349.00 for evaluation of her blutred and dimmed Vision Aer conducting an examination and taking the necessary restory De Ferrara diagnoses the patients condition as a cortical agereated cataract of the left eye that is close to mature ACD.10 CM H250121 Dr Ferrara decides to schedule Betty for sens extraction, the procedures ambulatory care surgery with same-day admission and discharge. The procedure will be done at Mischogle Hospital's Outpatients on 5/10/2020 Horton PPO requtres precertification for this procedure CPT 66984) PRECERTIFICATION FORM Insurance comes Certification for surgery and or acestion or Patient name Street address Citytrip Telephone Date of birth Subscriber name Employer Member no Gone Acting physican Provider no Hospitality Pinned procedure date Dugnas/symptoms Treatment procedure Estedeng of stay
