Understanding Health Insurance - Chapter 12: Commerical Insurance

I would like someone to check my work for accuracy as I may be missing something in this practice insurance billing form, please. Please let me know if I made any mistakes.

CONNECTICUT GENERAL PO BOX 1234 HEALTH INSURANCE CLAIM FORM HEALTH CT 012341234 APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12 PICA PICAT MEDICARE MEDICAID TRICARE CHAMPVA HEALTH PLAN BUKLUNG OTHER 18. INSURED'S I.D. NUMBER [For Program in Hem 1) (Medicare) (Modicaida) (10WVDoD4) Member 1D4) X (ID4) 210010121 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) GAYLE, IMA 09 30 1945 M F X GAYLE, IMA 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (NO., Street) 101 HAPPY DRIVE Sell X Spouse|Child Other 101 HAPPY DRIVE CITY STATE 8. RESERVED FOR NUCC USE CITY STATE ANYWHERE NY ANYWHERE NY ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) 123451234 12345-1234 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO 11. INSURED'S POLICY GROUP OR FECA NUMBER 101 a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH SEX YES X NO 09 30 1945 F X . RESERVED FOR NUCC USE b. AUTO ACCIDENT? PLACE (State) |b. OTHER CLAIM ID (Designated by NUCC) YES X NO . RESERVED FOR NUCC USE . OTHER ACCIDENT C. INSURANCE PLAN NAME OR PROGRAM NAME YES X NO CONNECTICUT GENERAL d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAIM CODES (Designated by NUCC) d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES X NO If yes, complete items 9, 9a, and 9d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED SIGNATURE ON FILE DATE SIGNED SIGNATURE ON FILE 14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP) 15. OTHER DATE MM DO ! YY 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 03 01 20YY QUAL 431 QUAL FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 178. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 176. NPI FROM TO 19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 20. OUTSIDE LAB? $ CHARGES YES NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E) ICD Ind. 22. RESUBMISSION ORIGINAL REF. NO. R20.0 B. M17 . 12 C. D. E 23. PRIOR AUTHORIZATION NUMBER F. G. H. K. I 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS RENDERING MM DD YY MM DO YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS QUAL PROVIDER ID. 03 |01 20YY 11 99213 25 A 601 00 1 NPI 03 / 01 20YY 11 20552 A 75 00 1 NPI160 G. RESERVED FOR NUCC USE C. OTHER ACCIDENT? C. INSURANCE PLAN NAME OR PROGRAM NAME YES X NO CONNECTICUT GENERAL d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAIM CODES (Designated by NUCC) d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES X NO If yes, complete Roms 9, 9a, and 9d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED SIGNATURE ON FILE DATE SIGNED SIGNATURE ON FILE 14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP) 15. OTHER DATE 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 03 01 20YY QUAL 431 QUAL DD YY FROM TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 178. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM 17b. NPI FROM TO 19. ADDITIONAL CLAIM INFORMATION (Designated by NUOC) 20. OUTSIDE LAB? $ CHARGES YES NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E) ICD Ind. 22. RESUBMISSION ORIGINAL REF. NO. R20.0 B M17 . 12 C. D. 23. PRIOR AUTHORIZATION NUMBER F. G. H. K. L. 24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS RENDERING MM DO YY MM DO YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS QUA PROVIDER ID. # 03 01 20YY 11 99213 25 A 60 0 1 NPI 03 | 01 20YY 11 20552 A 75 00 1 NPI NP 4 NPI NPI 6 NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. or port cli 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. Asvd for NUCC Use 111397992 X 1-2 X YES NO 135 100 50 00 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH INCLUDING DEGREES OR CREDENTIALS (101 ) 2022923 ( certify that the statements on the reverse SEJAL RAJA MD apply to this bill and are made a part thereof.) 1 MEDICAL DRIVE INJURY NY 123472347 SIGNED DATE a. 7890123456Case Study 1-2 Ima Gayle SEJAL RAJA MD 1 MEDICAL DRIVE INJURY NY 12347-2347 101 2022923 Patient Number: 1-2 EIN: 111397992 NPI: 7890123456 PATIENT INFORMATION: INSURANCE INFORMATION: Name: GAYLE, IMA Primary Insurance Address: 101 HAPPY DRIVE Primary Insurance Name: CONNECTICUT GENERAL City: ANYWHERE Address: PO BOX 1234 State: NY City: HEALTH Zip/4: 12345-1234 State: CT Telephone: 101 1119876 Zip/4: 01234-1234 Gender: M Fx Policy#: 210010121 Status: Single x Married Other Group #: 101 Date of Birth: 09 30 1945 Primary Policyholder: GAYLE, IMA Employer: MAIL BOXES INCORPORATED Address: 101 HAPPY DRIVE Student: FT PT School: City: ANYWHERE State: NY Work Related? N X Zip/4: 12345-1234 Auto Accident? N X State: Policyholder Date of Birth: 09 30 1945 Other Accident NY Pt Relationship to Insured: Self x Spouse Child Other Date of Accident Employer/School Name: MAIL BOXES INCORPORATED Secondary Insurance Referring Physician: Secondary Insurance Name: Address: Address: Telephone: City: NPI #: State: Zip/4: Policy#: Group #: Primary Policyholder: Address: City: State: Zip/4: Policyholder Date of Birth: Pt Relationship to Insured: Self Spouse Child Other Employer/School Name: ENCOUNTER INFORMATION: Place of Service: 11 DIAGNOSIS INFORMATION Code Diagnosis Code Diagnosis 1. R20.0 NUMBNESS, LEFT ARM 5. 2. M17.12 OSTEOARTHRITIS, LEFT KNEE B. 3. 7. PROCEDURE INFORMATION Unit Days/ Description of Procedure/Service Dates Code Mod Charge Units 1. OFFICE VISIT, ESTABLISHED PATIENT, 25 MINUTES 03 01 YYYY 99213 25 60 00 2. TRIGGER POINT INJECTION, TRAPEZIUS, LEFT 03 01 YYYY 20552 75 00 3. Special Notes: PATIENT PAID $50 OF TODAYS'S TOTAL