|| Directions with Performance Evaluation Checklist Study the EOB form in Workbook Figure 13-1, then calculate various figures and answer the following questions. 1st Attempt 2nd Attempt 3rd Attempt Gather materials (equipment and supplies) listed under Conditions. 1. How many patients' payment information is included on this EOB? 2. For patient Bradley Capell: What are the two dates procedures were performed? and 3. What was the total charge for both procedures? $ 4. Subtract the total amount allowed for both procedures from the total amount charged and indicate the "write off" amount. $ - 5. What is the total amount applied to the deductible for both procedures? $ 6. What was the total co-payment collected? $. 7. Subtract the total amount of the co-payment collected from the total amount allowed, then compare this amou with the total amount paid on Bradley Capell's claim; write this amount. $ 138 . For patient Margaret Champion: What service is being billed for on this claim? 9. What is the amount that will be written off the books? $ 4 10. What is the total amount paid on Margaret Champion's claim? Indicate the math to verify this amount 11! |||||||lli |||||ili TILLIT TIITTI 12 11 What is the total amount paid for both patients on this claims Complete within specified time Total points earned (To obtain a percentage score, divide the total points earned by the number of points possible) 35 Tyhetsch EXPLANATION OF BENEFITS BC Insurance Company PO Box 27894 Chicago, IL 95927-0004 Practon Medical Group, Inc. 4567 Broadway Avenue Woodland Hills, XY 12345-4700 Physician: Gerald M. Practon, MD Member: Yes Provider Number: 46278897XX 10-31-XX Issue Date: Page: Check No: 021820377 DATES PROCEDURE NUMMER BILLED AMOUNT ALLOWED AMOUNT NOTES DEDUCTIBLE UNITS OF SERVICE COPY AMOUNT PATIENT NAME ID NUMBER GROUP NUMER AMOUNT PAID PATIENT NUMBER CLAN NUMBER SERVICE CAP107 0716XX 62201 CAPELL BRADLEY 1000.00 20.75 720 170.62 017 52201 1000.00 20075 TOTAL 2000 M NOTES: 2 Because the physician or other health care provider is a member of ABC insurance, the allowed amount is accepted as payment in ful The subscriber is responsible only for deductibles, copayment amounts and noncovered items. $146.26 is the patient's copayment portion For questions regarding the above claim please call (800) 123-4567 CHAMPION MARGARET CAP10 SEX TOTAL NOTES 2 Because the physician or other health care provider is a member of ABC insurance, the allowed amount to accepted as payment in na The subscriber is responsible only for deductibles, coparment amounts and noncovered noms 545.00 is the patient's copayment portion. STATEMENT || Directions with Performance Evaluation Checklist Study the EOB form in Workbook Figure 13-1, then calculate various figures and answer the following questions. 1st Attempt 2nd Attempt 3rd Attempt Gather materials (equipment and supplies) listed under Conditions. 1. How many patients' payment information is included on this EOB? 2. For patient Bradley Capell: What are the two dates procedures were performed? and 3. What was the total charge for both procedures? $ 4. Subtract the total amount allowed for both procedures from the total amount charged and indicate the "write off" amount. $ - 5. What is the total amount applied to the deductible for both procedures? $ 6. What was the total co-payment collected? $. 7. Subtract the total amount of the co-payment collected from the total amount allowed, then compare this amou with the total amount paid on Bradley Capell's claim; write this amount. $ 138 . For patient Margaret Champion: What service is being billed for on this claim? 9. What is the amount that will be written off the books? $ 4 10. What is the total amount paid on Margaret Champion's claim? Indicate the math to verify this amount 11! |||||||lli |||||ili TILLIT TIITTI 12 11 What is the total amount paid for both patients on this claims Complete within specified time Total points earned (To obtain a percentage score, divide the total points earned by the number of points possible) 35 Tyhetsch EXPLANATION OF BENEFITS BC Insurance Company PO Box 27894 Chicago, IL 95927-0004 Practon Medical Group, Inc. 4567 Broadway Avenue Woodland Hills, XY 12345-4700 Physician: Gerald M. Practon, MD Member: Yes Provider Number: 46278897XX 10-31-XX Issue Date: Page: Check No: 021820377 DATES PROCEDURE NUMMER BILLED AMOUNT ALLOWED AMOUNT NOTES DEDUCTIBLE UNITS OF SERVICE COPY AMOUNT PATIENT NAME ID NUMBER GROUP NUMER AMOUNT PAID PATIENT NUMBER CLAN NUMBER SERVICE CAP107 0716XX 62201 CAPELL BRADLEY 1000.00 20.75 720 170.62 017 52201 1000.00 20075 TOTAL 2000 M NOTES: 2 Because the physician or other health care provider is a member of ABC insurance, the allowed amount is accepted as payment in ful The subscriber is responsible only for deductibles, copayment amounts and noncovered items. $146.26 is the patient's copayment portion For questions regarding the above claim please call (800) 123-4567 CHAMPION MARGARET CAP10 SEX TOTAL NOTES 2 Because the physician or other health care provider is a member of ABC insurance, the allowed amount to accepted as payment in na The subscriber is responsible only for deductibles, coparment amounts and noncovered noms 545.00 is the patient's copayment portion. STATEMENT