Professional Claim
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What claim form did the provider utilize to submit this?
CMS-1500
(wrong answers:
UB-04,
Medical Claim Form,
What the office uses)
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Who is the Rendering Provider?
Kaitlyn Hall
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What is the document number (for use in SmartData)?
CE19135019001
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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
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How much did the provider bill for services on this day?
$201.00
(wrong answers:
$50.00,
$20.00,
$0.00)
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What is the member copay?
$20.00
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Who added notes to this claim for the copay?
Curt