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Professional Claim

Created by alyssajuda

20190520P000121

  1.  
    What claim form did the provider utilize to submit this?
    A. UB-04 B. CMS-1500 C. Medical Claim Form D. What the office uses
  2.  
    Who is the Rendering Provider?
  3.  
    What is the document number (for use in SmartData)?
  4.  
    Enter the document number into SmartData. What is the address of the clinic that was visited?
  5.  
    How much did the provider bill for services on this day?
    A. $50.00 B. $20.00 C. $201.00 D. $0.00
  6.  
    What is the member copay?
  7.  
    Who added notes to this claim for the copay?
Answer Key
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Professional Claim (Answer Key)

Created by alyssajuda

20190520P000121

  1.  
    What claim form did the provider utilize to submit this?
    A. UB-04 B. CMS-1500 C. Medical Claim Form D. What the office uses
  2.  
    Who is the Rendering Provider?
    Kaitlyn Hall
  3.  
    What is the document number (for use in SmartData)?
    CE19135019001
  4.  
    Enter the document number into SmartData. What is the address of the clinic that was visited?
    516 3rd St Ste 100 Des Moines, IA 50309
  5.  
    How much did the provider bill for services on this day?
    A. $50.00 B. $20.00 C. $201.00 D. $0.00
  6.  
    What is the member copay?
    $20.00
  7.  
    Who added notes to this claim for the copay?
    Curt

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