) O~€¦ · ASSIGNMENT 3-7 ~ ABSTRACT DATA FROM AN INSURANCE IDENTIFICATION CARD Performance...
7
./v .•...•. +r->-: .• ASSIGNMENT 3-5 ABSTRACT DATA IDENTIFICATION FRO M CARD AN INSURANCE Conditions: Use an insurance identification card (Figure 3-2), the questions presented, and pen or pencil. Performance Objective Task: Answer questions in reference to an insurance identification card for Case A. Standards: Time: minutes Accuracy: _ (Note: The time element and accuracy criteria may be given by your instructor.) Directions: An identification card provides much of the information needed to establish a patient's insurance coverage. You have photocopied the front and back sides of three patients' cards and placed copies in their patient records, returning the originals to the patients. Answer the questions by abstracting or obtaining the data from the cards. C~EA I L Name of patient covered by the policy ---'L=-=I'-ntl-"'-=-"--·~L=-_!f!___'l~d~a.a...-- 2. Provide the insurance policy's effective date. ..:::S=--.-...:..\_-_Gi..:..I:::>_- _ jOb-- J..14-11 {, I _~. rtUt. ert95 oc. CtU..1. '(J( ,\,I. "'Oil").... PClOc A "107~ Mnovrc\ ) etLq 30 ::, t "4 .. 5. List the telephone number to call for provider access.-' -1('\) ~\ . -c.. ~l::\) E 6. Name the type of insurance plan. 1?r tJ O~ V\1- Bu • e r.. IJ.. n 7. List the insurance identification number (a.k,a. subscriber,certificate, or member numbers). t ))5- ~Cotl-O()~o'-Jtf 6t19Vfi:t. A S ·tJG~a III 0~ P\~" 8. Furnish the group number. Plan or coverage code. v , .~e, 9. State the capay requirements ~a.OCD ~1c.L- . 10. Does the card indicate the patient has hospital coverage? \~ .. .t-I_t-""-'s...z- _ , 3. List the telephone number for preauthorization. 4. State name and address of insurance company. + This is your employer health plan Identification card. Present it to the provider of Blue Cross health care when you or your eligible dependents receive services. See your certificate(s) or bookJet{s) for a description of your benefits. terms, conditions. limitations. and exclusion of California'" of coverage. When submitting inquiries always include your member number from the CALIFORNIA CARE face of this card. Possession or use of this card does not guarantee payment. HEALTH PLANS Type of Insurance: PRUDENT BUYER PLAN & WeUpoint Pharmacy (800) 700-2541 GROUP: C54G28 Ip'P'ol" BlueCard Provider Access (BOO) 81O-BLUE XDS - 564 - 00 - 9044 FOR BLUE CROSS AND BLUE SHIELD PROVIDERS NAnONWIDE, EFFECnVE DATE: 05-01-95 Please submit claims to your local Blue Cross and/or Blue shield plan. To ensure prompt LINDA L FIELD PLAN CODE: 5031 B claims processlnc. please include the three-oigit alpha prefix that precedes the patient's ldeminca.tiOO number listed on the front of this card PLAN 040: MEDICAL - WELLPOINT PHARMACY TO THE PROVIDER CLAIMS & INQUIRIES, =.o. BOX 9072 OXNARD CA 93031-9072 For pre-authorization or Pre-Service Review call: (800) 274-7767 • All Independent LIcense of the Blue Cross Association CUSTOMER SERVICE, 1-800-627-8797 a Registered Marl<of the Blue Cross Association. COPAY $20 OFFICE ~ Registered Mark of Well?oint Health Networks Inc. Hospital coverage: Yes Figure 3-2 Copyright © 2006, 2004, 2002, 19'19 by Elsevier, Inc. All rights reserved. CPT only Copyright © 2004. Current Procedural Terminology, 2005, Professional Edition, American Medical Association. All Rigbts Reserved.
Transcript of ) O~€¦ · ASSIGNMENT 3-7 ~ ABSTRACT DATA FROM AN INSURANCE IDENTIFICATION CARD Performance...
./v .•...•.+r->-: .•
ASSIGNMENT 3-5 ABSTRACT DATAIDENTIFICATION
FRO MCARD
AN INSURANCE
Conditions: Use an insurance identification card (Figure 3-2), the questionspresented, and pen or pencil.
Performance Objective
Task: Answer questions in reference to an insurance identification card for Case A.
Standards: Time: minutes
Accuracy: _
(Note: The time element and accuracy criteria may be given by yourinstructor.)
Directions: An identification card provides much of the information needed to establisha patient's insurance coverage. You have photocopied the front and back sides of threepatients' cards and placed copies in their patient records, returning the originals to thepatients. Answer the questions by abstracting or obtaining the data from the cards.
C~EA IL Name of patient covered by the policy ---'L=-=I'-ntl-"'-=-"--·~L=-_!f!___'l~d~a.a...--2. Provide the insurance policy's effective date. ..:::S=--.-...:..\_-_Gi..:..I:::>_- _
jOb-- J..14-11 {,I _~.rtUt. ert95 oc. CtU..1. '(J( ,\,I. "'Oil")....PClOc A "107~ Mnovrc\ ) etLq 30 ::,t "4 ..
5. List the telephone number to call for provider access.-' -1('\) ~\ .-c..~l::\)E6. Name the type of insurance plan. 1?rtJ O~V\1- Bu •e r . . IJ..n7. List the insurance identification number (a.k,a. subscriber,certificate, or member numbers). t ))5- ~Cotl-O()~o'-Jtf
6t19Vfi:t.AS ·tJG~a III 0 ~P\~"8. Furnish the group number. Plan or coverage code. v , . ~e,9. State the capay requirements ~a.OCD~1c.L- .
10. Does the card indicate the patient has hospital coverage? \~...t-I_t-""-'s...z- _,
3. List the telephone number for preauthorization.
4. State name and address of insurance company.
+ This is your employer health plan Identification card. Present it to the provider of
Blue Cross health care when you or your eligible dependents receive services. See your certificate(s)or bookJet{s) for a description of your benefits. terms, conditions. limitations. and exclusion
of California'" of coverage. When submitting inquiries always include your member number from theCALIFORNIA CARE face of this card. Possession or use of this card does not guarantee payment.HEALTH PLANS
Type of Insurance: PRUDENT BUYER PLAN &WeUpoint Pharmacy (800) 700-2541
GROUP: C54G28 Ip'P'ol" BlueCard Provider Access (BOO) 81O-BLUE
XDS - 564 - 00 - 9044 FOR BLUE CROSS AND BLUE SHIELD PROVIDERS NAnONWIDE,EFFECnVE DATE: 05-01-95 Please submit claims to your local Blue Cross and/or Blue shield plan. To ensure prompt
LINDA L FIELD PLAN CODE: 5031 B claims processlnc. please include the three-oigit alpha prefix that precedes the patient'sldeminca.tiOO number listed on the front of this card
PLAN 040: MEDICAL - WELLPOINT PHARMACY TO THE PROVIDER
CLAIMS & INQUIRIES, =.o. BOX 9072 OXNARD CA 93031-9072For pre-authorization or Pre-Service Review call: (800) 274-7767• All Independent LIcense of the Blue Cross Association
CUSTOMER SERVICE, 1-800-627-8797 a Registered Marl<of the Blue Cross Association.
COPAY $20 OFFICE~ Registered Mark of Well?oint Health Networks Inc.
Hospital coverage: Yes
Figure 3-2
Copyright © 2006, 2004, 2002, 19'19 by Elsevier, Inc. All rights reserved. CPT only Copyright © 2004. Current Procedural Terminology, 2005,Professional Edition, American Medical Association. All Rigbts Reserved.
ASSIGNMENT 3-7 ~ ABSTRACT DATA FROM AN INSURANCEIDENTIFICATION CARD
Performance Objective
Task: Answer questions in reference to the insurance identification card forCase C.
Conditions: Use an insurance identification card (Figure 3-4), the questionspresented, and pen or pencil.
Standards: Time: minutes
Accuracy: _
(Note: The time element and accuracy criteria may be given by yourinstructor.)
1. Patient's name covered by the policy. _L_\ ~--'~'---{)._F_I_o_r_e_~ _;__--------2. Provide the insurance policy's effective date, if there is one. _-_/_P-.:/:....A- _3. List the number to call for out-of-network preauthorization. 1- ~D -C{t.( 0\, -S1~(
Vnv~(ALUMl~Q11(L YDttJ"'3cA~O&tf+ ~ CJ:q vf~ '%"l ~ ~ D "5. List the telephone number to call for member inquiries. ,-C?'I d.z::;:,
'P()S li--PP:tln w f...A. j)
4. State name and address of insurance company.
6. Name the type of insurance plan.
7. List the insurance identification number (a.k.a. subscriber, certificate,
or member numbers). __ -"'~-'--'-''''--'''- _
8. Furnish the group number. '--"-='- -,-- ....• _
9. State the copay requirements, if any. __ ...::.....::.::=--'''''-''''~-'--'''~_''_'''___ __'==_....:::._'=''_ _
1O. Who is the patient's primary care physician? -.,. _
UNiTEDhealthcare pas PCP PlanWITH RX 0 - UHC
and MH/CDPCP: G. LOMAN
805-643-9973
LINDA L FLORESMember# 52170-5172
CALMAT
Group # 176422CaPAY: Office Visit $10 ER $50
Urgent $35
Electronic Claims PayorlD 87726
Call 800-842-5751 for Member Inquiries
This identification card is not proof of membership nor does itguarantee coverage. Persons with coverage that remains in forceare entitled to benefits under the terms and conditions of thisgroup health benefit plan as detailed iJ your benefit description.
IMPORTANT MEMBER INFORMATIONIn non-emergencies, call your Primary Care Physician to receivethe highest level of benefits. If you have an emergency andare admitted to a hospital, you are required to call yourPrimary Care Physician within two working days.For out of network services that require authorization, callthe Member Inquiries 800 number on the front of this card.MTH
Claim Address: P.O. Box 30990, Salt Lake City, UT 84130-0990
Figure 3--4
Copyright © 2006, 2004, 2001, 1999 by Elsevier, Inc. All rights reserved. CPT only Copyright © 2004. Current Procedural Terminology, 2005,Professional Edition, American Medical Association. All Rights Reserved,
ASSIGNMENT 3-6 ~ ABSTRACT DATA FROM AN IN~UHAN"'~IDENTIFICATION CARD
Performance Objective
Task: Answer questions in reference to the insurance identification card forCase B.
Conditions: Use an insurance identification card (Figure 3-3), the questionspresented, and pen or pencil.
Standards: Tline: nllnutes
Accuracy: _
(Note: The time element and accuracy criteria may be given by yourinstructor.)
L Patient's name covered by the policy. M__ r_--l-5_o~r_d.::.!....bL.J..!jCAv'_"_'_rY\..!._'_ _
2. Provide the insurance policy's effective date. O-"--"_----"O:....:..I_-_a""'-"(J/Q(~'-4.-----3. List the telephone number for pre authorization. '\. gOO - "0 '"" ?> - I '" q \
Blve Sh~e,,\~of WlPornl~i-'p£x)-3B/-d-a> I
4. State name of insurance company.
5. List the telephone number to call for patient benefits and eligibility.
6. Name the type of insurance plan. --E..P"""6"-- _7. List the insurance identification number (a.k,a. SUbS~~, L/ (0q q f..t, q
certificate, or member numbers). _+(t-L.~~'!...L_=_'5~-_=_=.....T:::__------~---Wro!~lIii. . L-8. Furnish the group number. Plan or coverage code. DCf 10,0 15tt~ft Oln
9. State the copay requirements, if any. ~OD e. \\5'\..00\ .10. List the Blue Shield Web site. tlJuJW \ b\uesh,el~c~,co~
Copyright © 1006, 2004, 2002, 1999 by Elsevier, Inc. All rights reserved. CPT only Copyright © 2004. Current Procedural Terminology; 20105;Professional Edition, American Medical Association. All Rights Reserved.
~Preferred Plan~
"
SUBSCRIBER NAME, EFFECTIVE OATEo
MTFORDHAM 010120XXSUBSCRIBER 10 NUMBER GROUP NUMBER PLAN CODE542AJC557469969 00P1901
CUSTOMER SERVICE
(800) 331-200 1
07/16/20XX
Figure 3-3
Use Blue Shield of California Preferred Physicians and Hospitals to receivemaximum benefrts.
Carry the Blue Shield Identification Card with you at all times and present itwhenever you or one of your covered dependents receives medical services.Read your employee bookJet/Health Services Agreement which summarizesthe benefits. provisions. limitations and exclusions of your plan. Your healthplan may require prior notification of any hospitalization and notification. withinone business day, of an emergency admission. Review of selected proceduresmay be required before some services are performed. To receive hospital pre-admission and pre-service reviews. call 1-800-343-1691. Your failure to call mayresult in a reduction of benefits.
For questions. including those related to benefits. and eligibility. call thecustomer service number listed on the front of this card.
The PPO logo on the front of this ID Card identifies you to preferred providersoutside the state of California as a member of the Blue Card PPO Program.
When you are outside of California call 1-800-810-2583 to locate the nearestPPO Provider. Remember, any services you receive are subject to the policiesand provisions of your group plan.
1D-23200-PPO REVERSE wWvv.blueshieldca.com
Copyright © 1006, 2004, 2002, 1999 by Elsevier, Inc. All rights reserved. CPT only Copyright © 2004. Current Procedural Terminology, 2005,Professional Edition, American Medical Association. All Rights Reserved.
ASSIGNMENT 3-7 ~ ABSTRACT DATA -FROM AN INSURANCEIDENTIFICATION CARD
Performance Objective
Task: Answer questions in reference to the insurance identification card forCase C.
Conditions: Use an insurance identification card (Figure 3-4), the questionspresented, and pen or pencil.
Standards: l1me: nllnutes
Accuracy: _
(Note: The time element and accuracy criteria may be given by yourinstructor.)
1. Patient's name covered by the policy. _
2. Provide the insurance policy's effective date, if there is one. _
3. List the number to call for out-of-network preauthorization. _
4. State name and address of insurance company. _
5. List the telephone number to call for member inquiries. _
6. Name the type of insurance plan. _
7. List the insurance identification number (a.k.a. subscriber, certificate,
orrnembernurnnbe~). _
8. Furnish the group number. _
9. State the copay requirements, if any. _
10. Who is the patient's primary care physician? ~---------------
:-:-_-'::·r·~'.;:;-..
.'_.',_.:i ...
..:..,.):
UNiTEDhealthcare This identification card is not proof of membership nor does itguarantee coverage_ Persons with coverage that remains in forceare entitled to benefits under the terms and conditions of thisgroup health benefit plan as detailed in your benefit description.
IMPORTANT MEMBER INFORMATIONIn non-emergencies. call your Primary Care Physician to receivethe highest level of benefits. If you have an emergency andare admitted to a hospital, you are required to call yourPrimary Care Physician within two working davs.For out of network services "that require authorization. call
the Member Inquiries 800 number on the front of this card.
LINDA L FLORESMember# 52170-5172
POS PCP PlanWITH RX 0 - UHC
and MH/CDPCP: G. LOMAN
805-643-9973CALMAT
Group # 176422COPAY:Office VISit $10 ER$50
Urgent $35
Electronic Claims Payor ID 'ifTl26 MTHClaim Address: P.O_Box 30990. Salt Lake City, UT.8413G-0990
Figure 3-4
Copyright@ 2006, 2004, 2002, 1999 by Elsevier, Ine. All rights reserved,CPT only Copyright@ 2004. Current Procedural Tenninology, 2005,. Professional Edition, •American Medical Association.fill Rights Reserved.
ASSIGNMENT 3-5 ~ ABSTRACT DATA FROM AN INSURANCEIDENTIFICATION CARD
Performance Objective
Task: Answer questions in reference to an insurance identification card for Case A.
Conditions: Use an insurance identification card (Figure 3-2), the questionspresented, and pen or pencil.
Standards: Time: ~ minutes
Accuracy: _
(Note: The time element and accuracy criteria may be given by yourinstructor.)
Directions: An identification card provides much of the information needed to establisha patients insurance coverage. You have photocopied the front and back sides of threepatients' cards and placed copies in their patient records, returning the originals to thepatients. Answer the questions by abstracting or obtaining the data from the cards,
CASE AL Name of patient covered by the policy ~ _
2_ Provide the insurance policy's effective date _
3. List the telephone number for preauthorization _
4. State name and address of insurance company ~ _
5_ List the telephone number to call for provider access _
6. Name the type of insurance plan _
7_ List the insurance identification number (a.k,a. subscriber, certificate, or member numbers) ----
8. Furnish the group number. Plan or coverage code. _-==---.-c- _9_ State the copay requirements '-- _
10_ Does the card indicate the patient has hospital coverage? _
+.,~ ~ Blue Cross
~ of California'CAUFORNIA CARE
HEAl. TH PlANSPRUDENT BUYER PLAN ~ caro) 700-254 f
(BOO) 811}-8l.UE
TO THE PROVIDER:For pre-_ or Pre-Service"""'eu caIt (BOO)Zl4-n07~ An Independent Ucense of the Blue Cross Association.•• Regis!ered Mark cI the Blue Cross Associ2Iio!1.if Regislera(! Mark 01 \o\IeII?oint Health NetworKS Inc.
HospilaI covemge: Yes
Th!s is 'fCU' employe< heal!h plan ldentilicalio:l earn. Present ij to !he proviacf ojhealth care when you or your eligible depenCents receive services. See your certifica1e(s)O! _.(.) for a descrip1ion of yrnr _ teres. condiUons.limilations. and ex .
of ccveraqe, When submi!tiog U1quDies always ix:Iude yoor member numbe< ITom theface of!t"Js card. Possession or use of this card does not guarantee payment.
Type of Insurance:
!p'P'oj"EFfECTIVE DATE: 05-01-95PLAN CODE: 50318
GROUP: C54G28
XOS - 564 - 00 - 9044
LINDA L FIELDFOR BLUEGRass AND BLUE SHl8D PROVIDERS NAllONWIDEPlease submit claims to yoor local Blue Cross _ Blue shield plan. To ensure Ilfomp!claims processing. please .'lCIude the tI1<_git alpha prefix lhat precedes the patient'Si<\.,@icaOO:.number fisted on !he ITont of fIlis card.
PLAN 040: MEDlCAl- WELLPOINT PHARMACY
ClAIMS & INQUIRIES: P.O. BOX 9072 OXNARD CA 93031-9072CUSTOMER SERVICE: 1-800-S27-8797
COPAY S20 OFFICE
Figure 3-2
Copyright © 1006. 2004, wm, 19'19by Elsevier, Ine. All riglt15 reserved. CPT only Copyright © 1004. Current Procedural Tenninology, 1005,Professional Edition. American ~ledical Association. .:\IIRigb15 Reserved,
ASSIGNMENT 3-6 ~ ABSTRACT DATA FROM AN IN~UHAN"t:
IDENTIFICATION CARD
Performance Objective
Task: Answer questions in reference to the insurance identification card forCaseB.
Conditions: Use an insurance identification card (Figure 3-3), the qnestionspresented, and pen or pencil.
Standards: Tune: minutes
Accuracy: _
(Note: The time element and accuracy criteria may be given by yourinstructor.)
1. Patient's name covered by the policy. _
2. Provide the insurance policy's effective date. _
3. List the telephone number for preauthorization. _
4. State name of insurance company. _
5. List the telephone number to call for patient benefits and eligibility. _
6. Name the type of insurance plan. _
7. List the insurance identification number (a.k.a. subscriber,
certificate, or member numbers).
8. Furnish the group number. Plan or coverage code. _
9. State the copay requirements, if any. _
10. List the Blue Shield Web site. _
Copyright@ 2006, 2004, 2002, 1999 by Elsevier; lnc. All rights resented. CPT only Copyright © 2004. Current Procedural Te~minoIOlrr;'2~005;;.··:<· ::\.'" :<".Professional Edition. American Medical Association. All Rights Reserved.
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