The Central Clinic is fine tuning its electronic claim submissions You have been asked to audit the electronic claim form of the EHR and identify any missing fields in the forms electronic format that could cause the claim to be rejected Review the paper claim form found in the Resources section of this activity Compare each field on the paper form to the electronic version in the Claims and Ledger sections of the EHR found under the Account tab For each of the fields listed, which are numbered corresponding to their number on the paper form, indicate whether the field is completely present, partially present not clear or not present on the electronic claim by highlighting the correct choice Please note that you are auditing the availability of the fields themselves, and not the patient data, or lack thereof, entered in the fields Insurance type Insureds I D Number Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Patients name Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Patient Birth Date Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Insureds name Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Patients address Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Patients relationship to insured Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Insureds address Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Patient status Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Other insureds name Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Is the patients condition related to (employment auto accident other accident) Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Insureds policy group or FECA number, date of birth, employer, plan name, benefit plan name (if applicable) Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Authorization release Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Insureds signature Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Date of condition Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim First date of condition Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Dates patient unable to work in current occupation Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Name of referring physician, I D number of referring physician Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Hospitalization dates related to current services Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim N A (Reserved for local use) Skip to next question Outside lab charges Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Diagnosis or nature of illness or injury Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Medicaid resubmission code (if applicable) Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Prior authorization number (if applicable) Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Procedural codes for services rendered and related diagnostic code pointer Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Federal tax I D number Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Patients account number Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Accept assignment Yes or No Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim For 28 30, see the Ledger Tab Keep in mind that you are auditing the availability of the fields themselves, and not the patient data, or lack thereof, entered in the fields Total charges Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Amount paid Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Balance due Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Signature of physician to be reimbursed Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Name and address of facility where the services were rendered Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim Physicians, suppliers billing name, address, zip code, and phone number Completely present on electronic claim Partially present or not clear on electronic claim Not present on electronic claim List the items that were not completely present or were missing from the electronic claim Of the missing or incomplete items, which do you think would be most likely to cause this electronic claim to be rejected

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The Central Clinic is fine-tuning its electronic claim submissions. You have been asked to audit the electronic claim form of the EHR and identify any

The Central Clinic is fine-tuning its electronic claim submissions. You have been asked to audit the electronic claim form of the EHR and identify any missing fields in the forms electronic format that could cause the claim to be rejected. Review the paper claim form found in the Resources section of this activity. Compare each field on the paper form to the electronic version in the Claims and Ledger sections of the EHR found under the Account tab. For each of the fields listed, which are numbered corresponding to their number on the paper form, indicate whether the field is completely present, partially present/not clear or not present on the electronic claim by highlighting the correct choice. Please note that you are auditing the availability of the fields themselves, and not the patient data, or lack thereof, entered in the fields.

Insurance type & Insureds I.D. Number
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Patients name
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Patient Birth Date
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Insureds name
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Patients address
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Patients relationship to insured
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Insureds address
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Patient status
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Other insureds name
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Is the patients condition related to (employment/auto accident/other accident)
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Insureds policy group or FECA number, date of birth, employer, plan name, benefit plan name (if applicable)
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Authorization release
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Insureds signature
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Date of condition
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
First date of condition
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Dates patient unable to work in current occupation
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Name of referring physician, I.D. number of referring physician
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Hospitalization dates related to current services
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
N/A (Reserved for local use). Skip to next question.
Outside lab charges?
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Diagnosis or nature of illness or injury
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Medicaid resubmission code (if applicable)
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Prior authorization number (if applicable)
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Procedural codes for services rendered and related diagnostic code pointer
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Federal tax I.D. number
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Patients account number
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Accept assignment? Yes or No
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim

For 28-30, see the Ledger Tab. Keep in mind that you are auditing the availability of the fields themselves, and not the patient data, or lack thereof, entered in the fields.

Total charges
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Amount paid
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Balance due
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Signature of physician to be reimbursed
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Name and address of facility where the services were rendered
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
Physicians, suppliers billing name, address, zip code, and phone number
1. Completely present on electronic claim
2. Partially present or not clear on electronic claim
3. Not present on electronic claim
List the items that were not completely present or were missing from the electronic claim.
Of the missing or incomplete items, which do you think would be most likely to cause this electronic claim to be rejected?