INSURANCE INFORMATION: Primary Insurance
SimClaimTM Case Studies: Set One
Case Study 1-4 Katlyn Tiger
ARNOLD YOUNG MD 21 PROVIDER STREET INJURY NY 12347
101 2027754
EIN: 111234632
PATIENT INFORMATION: Name: TIGER, KATLYN Address: 2 JUNGLE ROAD City: NOWHERE State: NY Zip/4: 12346-1234 Telephone: 101 1112222
Gender: M F x Status: Single x Married Other Date of Birth: 01 03 1954 Employer: JOHN LION CPA Student: FT PT School:
Work Related? Y N x Auto Accident? Y N x State: Other Accident: Y N x Date of Accident:
Referring Physician: Address: Telephone: NPI #:
Patient Number: 1-4
NPI: 0123456789
Primary Insurance Name: BLUECROSS BLUESHIELD Address: PO BOX 1121 City: MEDICAL State: PA Zip/4: 12357-1121
Plan ID#: ZJW334444 Group #: W310 Primary Policyholder: TIGER, KATLYN Address: 2 JUNGLE ROAD City: NOWHERE State: NY Zip/4: 12346-1234 Policyholder Date of Birth: 01 03 1954 Pt Relationship to Insured: Self x Spouse Child Other Employer/School Name: JOHN LION CPA
INSURANCE INFORMATION: Primary Insurance
Secondary Insurance Secondary Insurance Name: Address: City: State: Zip/4:
Plan ID#: Group #: Primary Policyholder: Address: City: State: Zip/4: Policyholder Date of Birth: Pt Relationship to Insured: Self Spouse Child Other Employer/School Name:
ENCOUNTER INFORMATION: Place of Service: 22
DIAGNOSIS INFORMATION
PROCEDURE INFORMATION
Description of Procedure/Service
1. INITIAL OBSERVATION, COMPREHENSIVE
Dates Code Mod Unit Charge
Days/ Units
Code
1. J18.0 BRONCHOPNEUMONIA
Diagnosis Code
5.
Diagnosis
2.
3.
4.
3.
4.
5.
6.
Special Notes: CARE RENDERED AT GOODMEDICINE HOSPITAL, 1 PROVIDER STREET, ANYWHERE, NY 12345, NPI: 1123456789. ADMISSION 2/28/YYYY DISCHARGE 3/1/YYYY
02 28 YYYY
03 01 YYYY
99220
99217
175 00
65 00
1
1
6.
7.
8.
2. DISCHARGE HOME
