ASSIGNMENT 4.3 - subsequent to related hospitalizations In...

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LASHAUNDA N. MONROE JANUARY 15, 2009 The importance of entering an X in the yes box in block 10 B is to notify the insurance company weather employment auto liability or other accident involvement applies to one or more of the services being described in item 24. Enter the state postal code. Any item checked yes indicates there may be other insurance primary to Medicare. Identify other primary insurance in item 11. It is necessary for the patient to sign block 12 when the patient authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of services or supplier, when the provider of services or supplier accepts assignment on the claim. Section 18 should be completed when a medical service is furnished as a result of or
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Unformatted text preview: subsequent to related hospitalizations. In block 14 a date should be entered when there is a current date of illness, injury or pregnancy. In block 21 the patient’s diagnosis/condition should be entered. You should enter the diagnosis code only, not the description. Enter up to four primary order codes. An independent laboratory must enter a diagnosis only for limited coverage procedures. INSURANCE DEDUCTIBLE CO-INSURANCE CO-PAY BILLING METHOD MADICARE PART B $135 ANNUAL 0-60= $0.00 $ 2.00 PER VISIT WITHDRAWN FROM SOCIAL SECURITY CHECK MEDICAID NONE $0.00 DEPENDING ON $2.00 PER VISIT $25.00 HOSPITAL STAY ELECTRONIC TRICARE $235 ANNUAL PER FAMILY UNTIL 65 YEARS OLD $ 12.00 PER VISIT MANUAL AND ELECTRONIC...
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