The objective of these exercises is to correctly complete TRICARE claims, applying what you have learned in the chapter. Following the information about the provider for the cases are two sections. The first section contains information about the patient, the insurance coverage, and the current medical condition. The second section is an encounter form for Valley Associates, PC. If you are gaining experience by completing a paper CMS-1500 claim form, use the blank claim form supplied to you (from the back of the book or printed from the books Online Learning Center) and follow the instructions on pages 255256 to fill in the form by hand. Alternatively, the Online Learning Center provides an electronic CMS-1500 form that can be used to fill in and print claims. See The Interactive Simulated CMS-1500 Form in Appendix B at the back of this text for further instructions. The following provider information should be used for the case studies in this chapter.

Provider Information Name Nancy Ronkowski, MD Address 1400 West Center Street Toledo, OH 43601-0213 Telephone 555-321-0987 Employer ID Number 06-7890123 NPI 9475830260 Assignment Accepts Signature On File (1-1-2016)

Case 11.1 LO 11.2LO 11.4 From the Patient Information Form: Name Robyn Janssen Sex F Birth Date 02/12/1984 Marital Status M Address 310 Wilson Ave. Brooklyn, OH 44144-3456 SSN 334-62-5079 Health Plan TRICARE Signature On File 01/01/16 Information About the Insured: Insured Lee Janssen Patient Relationship to Insured Spouse Date of Birth 01/05/1984 Sex M Address Box 404 Fort Dix, NJ 08442-3456 Telephone 555-442-3600 SSN 602-37-0442 Insurance Plan TRICARE Insurance ID Number 602370442 Signature On File Copayment $10

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