wk 4
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| Box 1 | Type of insurance
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| Box 2 | Patient name
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| Box 3 | Patient Birthday and gender
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| Box 4 | Insureds name
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| Box 1a | Insureds ID #
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| Box 5 | Patients address
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| Box 6 | Patient relationship to insured
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| Box 7 | Insureds address
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| Box 8 | Reserved for NUCC use
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| Box 9 and a-d | Other insureds name
a. Other insureds policy or grp #
b. Reserved for NUCC use
c. Reserved for NUCC use
d. Insurance plan name or program name
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| Box 10 and 10d | Is patients condition related to
10d claims codes
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| Box 11 | Insureds policy grp or feca #
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| Box 12 | Patient or authorized person signature
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| Box 13 | Insureds or authorized persons signature
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| Box 14 | Date of current illness
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| Box 15 | Other date
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| Box 16 | Dates patient unable to wrk in current occupation
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| Box 17 | Name of referrering provider or other source
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| Box 18 | Hospitalization dates related to current services
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| Box 19 | Additional claim information
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| Box 20 | Outside labs
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| Box 21 | ICD-10 codes diagnosis or nature of illness or injury
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| Box 22 | Resubmission code
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| Box 23 | Prior authorization number
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| Box 24a-j | 24a dates of service
b. Place of service
c. Emg
d. Cpt/hcpcs....modifier procedure, services, or supplies
e. Diagnosis pointer
f. Charges
g. Days or units
h. East family plan
I. ID qual/npi
j. Rendering provider
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| Box 25 | Federal tax id number
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| Box 26 | Patients account #
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| Box 27 | Accept assignment
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| Box 28 | Total charge
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| Box 29 | Amount paid
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| Box 30 | Reserved for NUCC use
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| Box 31 | Dr. Signature
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| Box 32 | Service facility location information
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| Box 33 | Billing provider info and phone #
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Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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Created by:
cheri le
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