WK8 ASSIGNMENT2 HP-214
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WK8ASSIGNMENT2HP214_Patient_Registration_Form.docx
WK8ASSIGNMENT2INFOHP-214.docx
- WK8ASSIGNMENT2HP-214form-cms1500.pdf
WK8ASSIGNMENT2HP-214.docx
WK8 ASSIGNMENT2 HP-214
Use the registration form to complete a CMS-1500 Claim Form for a Workman’s Comp Patient.
Open the patient registration information
Open a blank fillable CMS-1500 form
When doing this assignment, remember to:
· Use the NUCC Instructions to complete your CMS-1500
· Review your completed form for errors
WK8ASSIGNMENT2HP214_Patient_Registration_Form.docx
Patient Registration Form
Patient Information:
Full Name: Jane A. Doe
Date of Birth (MM/DD/YYYY): 06/15/1985
Gender: Female
Social Security Number: 123-45-6789
Address: 123 Main Street
City: Springfield State: IL Zip Code: 62704
Phone Number: (217) 555-7890
Email Address: [email protected]
Marital Status: Single
Employment Status: Employed
Employer Name (if applicable): ABC Corporation
Emergency Contact Name: John Doe
Relationship to Patient: Brother
Emergency Contact Phone: (217) 555-1234
Insurance Information:
Primary Insurance Provider: Illinois Workers’ Compensation Board
Policy Number: ILWC-202504-001
Group Number: N/A
Insurance Phone Number: (800) 555-WCIL
Policyholder Name: Jane A. Doe
Policyholder Date of Birth (MM/DD/YYYY): 06/15/1985
Patient’s Relationship to Policyholder: Self
Secondary Insurance Provider (if applicable): N/A
Secondary Policy Number: N/A
Medical Provider Information:
Referring Physician Name: Dr. Emily Carter
NPI Number: 1234567890
Facility Name: Springfield Medical Center
Facility Address: 456 Health Ave, Springfield, IL 62704
Facility Phone Number: (217) 555-9876
Tax ID or EIN (if required): 12-3456789
Authorization and Consent:
I certify that the information provided above is true and correct to the best of my knowledge. I authorize the release of medical information necessary to process my insurance claims. I also authorize payment of medical benefits to the provider for services rendered.
Patient Signature: Jane A. Doe Date: 02/25/2025
For Office Use Only:
Patient ID Number: 001234567
Date of Service: 02/25/2025
Insurance Verified: Yes
Copay Collected: No Amount: $0.00
CPT Code: 99213
Diagnosis Code: S61.409A
Amount Charged: $150.00
Staff Initials:
Note: This is a Workers' Compensation case. No copay is required. Charges for evaluation and treatment should be submitted in accordance with WC guidelines. Estimated service charge: $350.00 (to be itemized on CMS-1500).
WK8ASSIGNMENT2INFOHP-214.docx
Workman’s Compensation
The federal and state governments work together using a two-pronged approach to support the health of workers. The first approach is through agencies to promote safety and the second is through the workers’ compensation insurance program that is meant to minimize the effects of a work-related injury or illness and to provide medical and financial support during treatment.
The agency that promotes workplace safety and employee support processes is the Department of Labor. Occupational Safety and Health Administration (OSHA) is known to most individuals who have been employed. Safety standards and oversight provided by OSHA are designed to prevent work-related illnesses and injuries. But when work-related illnesses or injuries do occur the workers’ compensation program is there to provide medical care and financial support.
Workers' compensation is implemented primarily at the state level and each state may emphasize different aspects of the program. The federal government also has a separate workers' compensation program, which is mostly for federal employees. Each State will, by Federal Law, include the following classifications under their workers’ comp—program: medical treatment, temporary disability, permanent disability, vocational rehabilitation, and survivor benefits.
In medical facilities, it is important to know that providers are required to accept workers’ compensation-allowable fee as payment in full for covered services on cases involving on-the-job illnesses and injuries. Also, in order to be HIPAA compliant, the State Compensation Boards and payers can review history and treatment data pertaining to a patient’s on-the-job injury only.
When a work-related illness or injury occurs, the first provider to attend to the worker is responsible for completing the “first report of injury form”. An example of this form is found on page 605 of your text. A copy of this form needs to be provided to the State Workers’ Compensation Board/Commission, the employer-designated compensation payer, the ill or injured party’s employer, and to the newly produced patient’s work-related injury chart. There is a time limit for filing this form, which varies from 24 hours to 14 calendar days, depending on state requirements. Medical personnel must contact the patient’s employer to obtain the name and mailing address of the compensation payer.
Billing notes for Workers’ Compensation patients include:
· Deductible - None for workers’ compensation claims
· Copayment - None for workers’ compensation cases
· State compensation board establishes a schedule of approved fees.
· Providers must accept compensation payment as payment in full.
Sometimes the communication that would flag the need for a workers’ compensation claim is delayed. If a private payer is mistakenly billed the initial Workers’ Compensation claim will most likely be denied. The patient must initiate the appeals process with Workers’ Compensation. The provider will be responsible for submitting supporting documentation to Workers’ Compensation and will need to reimburse any payment made by the primary payer. This scenario emphasizes the need to carefully review with patients whether an illness or injury is work-related.
Special handling for Workers’ Compensation claims includes:
· Contacting the employer immediately when the injured worker presents for a first visit without written or personal referral from the employer.
· When processing the First Report of Injury, a progress report, or billing forms no patient signature is needed.
· If an established patient seeks treatment for a work-related injury, create a separate compensation chart and ledger or account.
Processing a Workers’ Compensation claim includes the use of the CMS 1500 form. Instructions for completing this claim are found on page 612 in your text.
In this course, we have covered the most often encountered insurance types that you will find if you choose to work as a medical billing specialist. Your text has done an excellent job presenting instructions for completing the forms for these insurance types. I highly recommend that you return to each chapter to copy and paste these instructions and save the information in your private file. This would make an excellent resource for you while working in your field of choice.
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