Professional Claim

Question or Hint Answer or Word
  1. What claim form did the provider utilize to submit this? CMS-1500 (wrong answers: UB-04, Medical Claim Form, 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? $201.00 (wrong answers: $50.00, $20.00, $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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