Table Summary: Table summarizes $10$ different fields with details for patient information and $15$ different fields with details for insured's information.

Information About the Patient:

Name Kalpesh Shah

Sex M

Birthdate $01/21/2016$

Marital Status Single

Address $1433$ Third Ave

$$ Cleveland, OH

$44101-1234$

Telephone $555-608-9772$

Employer Not Employed

Race White

Ethnicity Not Hispanic or Latino

Preferred Language English

Information About the Insured:

Insured Raj Shah

Patient Relationship to Insured Child

Sex M

Birthdate $02/16/1987$

Marital Status Married

Address $1433$ Third Ave

$$ Cleveland, OH

$44101-1234$

Telephone $555-608-9772$

Employer Cleveland Savings Bank

Health Plan Oxford Freedom PPO

Insurance ID Number $3302112090$X

Policy Number $0946582$

Group Number G$0904$

Copayment$/$Deductible Amount $$15$ copay

Assignment of Benefits Y

Signature on File $01/01/2029$

Condition Unrelated to Employment, Auto Accident, or Other AccidentPage $253$

Questions

LO $7\mathrm{.}27\mathrm{.}5$ Are the subscriber and the patient the same person?

LO $7\mathrm{.}27\mathrm{.}5$ What is the code for the patient$$s relationship to the insured?

LO $7\mathrm{.}27\mathrm{.}5$ What is the claim filing indicator code?

LO $7\mathrm{.}27\mathrm{.}5$ What amount is being billed on the claim?

LO $7\mathrm{.}27\mathrm{.}5$ What claim control number would you assign to the claim?