nstructions:

Obtain a blank CMS$-1500$ form Download CMS$-1500$ formand make a copy of it to complete this exercise.

Review the Mary S$.$ Patient case study $($Figure $12-3).$ See below:

Select the information needed for Blocks $1$ through $33,$ and enter the required information on the blank CMS$-1500$ claim.

Review the completed claim to be sure that all required blocks are completed accurately.

Step $2$: Complete Exercise $12\mathrm{.}1$ Completing a Commercial as Primary CMS$-1500$ Claim

Please complete the CMS$-1500$ Claim form per instructions and submit it by Sunday at $11$:$59$ pm PST$.$

Don't hesitate to contact your instructor with questions or concerns.

Figure $12-3$

W$3$ Exercise $12\mathrm{.}1$ Question $1$ Image.PNG