ANSWER KEY
BlueCross BlueShield Case 1
Required fields: 51
Primary Form
BLUECROSS BLUESHIELD
PO BOX 1121
CARRIER
HEALTH INSURANCE CLAIM FORM MEDICAL PA 123571121
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. NUMBER (For Program in Item 1)
HEALTH PLAN BLK LUNG
ZJW334444703
(Medicare#) (Medicaid#) (ID#/DoD#) (Member ID#) (ID#) (ID#) (ID#)
2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE Sex 4. INSURED'S NAME (Last Name, First Name, Middle Initial)
MM DD YY
VANG, TANYA M F VANG, TANYA
01 03 1964
5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street)
2 BIRCH ROAD Self Spouse Child Other 2 BIRCH ROAD
CITY STATE 8. RESERVED FOR NUCC USE CITY STATE
ELM SPRINGS NY ELM SPRINGS NY
PATIENT AND INSURED INFORMATION
ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
155686789 ( ) 155686789 ( )
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER
1155432
a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH Sex
MM DD YY
Yes No M F
01 03 1964
b. RESERVED FOR NUCC USE b. AUTO ACCIDENT? PLACE (State) b. OTHER CLAIM ID (Designated by NUCC)
Yes No
c. RESERVED FOR NUCC USE c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
Yes No BLUECROSS BLUESHIELD
d. INSURANCE PLAN NAME OR PROGRAM NAME d. CLAIM CODES (Designated by NUCC) d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, complete items 9, 9a, and 9d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENTS'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary to process this payment of medical benefits to the undersigned physician or supplier for
claim. I also request payment of government benefits either to myself or the party who accepts assignment below. services described below.
SIGNED SIGNATURE ON FILE DATE SIGNED
, 14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY(LMP) 15. OTHER DATE 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD YY MM DD YY MM DD YY MM DD YY
QUAL. 431 QUAL.
02 28 YY FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
17a.
MM DD YY MM DD YY
17b. NPI FROM TO
19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 20. OUTSIDE LAB? $ CHARGES
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E) 22. RESUBMISSION
ICD Ind. 0
CODE ORIGINAL REF. NO.
A. J180 B. C. D.
E. F. G. H. 23. PRIOR AUTHORIZATION NUMBER
I. J. K. L.
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
(Explain Unusual Circumstances) DAYS EPSDT
FROM TO
PLACE OF DIAGNOSIS OR Family ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS Plan QUAL. PROVIDER ID. #
PHYSICIAN OR SUPPLIER INFORMATION
1
02 28 YY 22 99223 A 175 00 1 NPI
2
03 01 YY 22 99238 A 65 00 1 NPI
3
NPI
4
NPI
5
NPI
6
NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. Rsvd for NUCC Use
(For govt. claims, see back)
111234632 30022
YES NO $ 240 00 $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING 32. SERVICE FACILITY LOCATION INFORMATION (
33. BILLING PROVIDER INFO & PH # 101 5557754 )
DEGREES OR CREDENTIALS
( I certify that the statements on the reverse apply to this bill and
CENGAGE HOSPITAL ARNOLD YOUNG MD
are made a part thereof.) 1 PROVIDER STREET 21 PROVIDER STREET
WELLSTONE NY 123451234 INJURY NY 123472347
SIGNED ARNOLD YOUNG MD DATE 030123 a. 1123456789 b. a. 0123456789 b.
NUCC Instruction Manual available at: www.nucc.org PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12)
, ANSWER KEY
BlueCross BlueShield Case 2
Required fields: 44
Primary Form
BLUECROSS BLUESHIELD
PO BOX 1121
CARRIER
HEALTH INSURANCE CLAIM FORM MEDICAL PA 123571121
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. NUMBER (For Program in Item 1)
HEALTH PLAN BLK LUNG
XWV779448358
(Medicare#) (Medicaid#) (ID#/DoD#) (Member ID#) (ID#) (ID#) (ID#)
2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE Sex 4. INSURED'S NAME (Last Name, First Name, Middle Initial)
MM DD YY
CHU, JEFFREY, A M F CHU, JEFFREY, G
02 03 2015
5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street)
103 MOUNTAIN VIEW ROAD Self Spouse Child Other 103 MOUNTAIN VIEW ROAD
CITY STATE 8. RESERVED FOR NUCC USE CITY STATE
ELM SPRINGS NY ELM SPRINGS NY
PATIENT AND INSURED INFORMATION
ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
155686789 ( ) 155686789 ( )
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER
8762145
a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH Sex
MM DD YY
Yes No M F
07 01 1978
b. RESERVED FOR NUCC USE b. AUTO ACCIDENT? PLACE (State) b. OTHER CLAIM ID (Designated by NUCC)
Yes No
c. RESERVED FOR NUCC USE c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
Yes No BLUECROSS BLUESHIELD
d. INSURANCE PLAN NAME OR PROGRAM NAME d. CLAIM CODES (Designated by NUCC) d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, complete items 9, 9a, and 9d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENTS'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary to process this payment of medical benefits to the undersigned physician or supplier for
claim. I also request payment of government benefits either to myself or the party who accepts assignment below. services described below.
SIGNED SIGNATURE ON FILE DATE SIGNED
, 14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY(LMP) 15. OTHER DATE 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD YY MM DD YY MM DD YY MM DD YY
QUAL. 431 QUAL.
03 10 YY FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
17a.
MM DD YY MM DD YY
17b. NPI FROM TO
19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 20. OUTSIDE LAB? $ CHARGES
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E) 22. RESUBMISSION
ICD Ind. 0
CODE ORIGINAL REF. NO.
A. J209 B. J310 C. D.
E. F. G. H. 23. PRIOR AUTHORIZATION NUMBER
I. J. K. L.
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
(Explain Unusual Circumstances) DAYS EPSDT
FROM TO
PLACE OF DIAGNOSIS OR Family ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS Plan QUAL. PROVIDER ID. #
PHYSICIAN OR SUPPLIER INFORMATION
1
03 10 YY 11 99212 AB 26 00 1 NPI
2
NPI
3
NPI
4
NPI
5
NPI
6
NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. Rsvd for NUCC Use
(For govt. claims, see back)
111397992 43111
YES NO $ 26 00 $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING 32. SERVICE FACILITY LOCATION INFORMATION (
33. BILLING PROVIDER INFO & PH # 101 5552923 )
DEGREES OR CREDENTIALS
( I certify that the statements on the reverse apply to this bill and
SEJAL RAJA MD
are made a part thereof.) 1 MEDICAL DRIVE
INJURY NY 123472347
SIGNED SEJAL RAJA MD DATE 030123 a. b. a. 7890123456 b.
NUCC Instruction Manual available at: www.nucc.org PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12)
BlueCross BlueShield Case 1
Required fields: 51
Primary Form
BLUECROSS BLUESHIELD
PO BOX 1121
CARRIER
HEALTH INSURANCE CLAIM FORM MEDICAL PA 123571121
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. NUMBER (For Program in Item 1)
HEALTH PLAN BLK LUNG
ZJW334444703
(Medicare#) (Medicaid#) (ID#/DoD#) (Member ID#) (ID#) (ID#) (ID#)
2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE Sex 4. INSURED'S NAME (Last Name, First Name, Middle Initial)
MM DD YY
VANG, TANYA M F VANG, TANYA
01 03 1964
5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street)
2 BIRCH ROAD Self Spouse Child Other 2 BIRCH ROAD
CITY STATE 8. RESERVED FOR NUCC USE CITY STATE
ELM SPRINGS NY ELM SPRINGS NY
PATIENT AND INSURED INFORMATION
ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
155686789 ( ) 155686789 ( )
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER
1155432
a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH Sex
MM DD YY
Yes No M F
01 03 1964
b. RESERVED FOR NUCC USE b. AUTO ACCIDENT? PLACE (State) b. OTHER CLAIM ID (Designated by NUCC)
Yes No
c. RESERVED FOR NUCC USE c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
Yes No BLUECROSS BLUESHIELD
d. INSURANCE PLAN NAME OR PROGRAM NAME d. CLAIM CODES (Designated by NUCC) d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, complete items 9, 9a, and 9d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENTS'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary to process this payment of medical benefits to the undersigned physician or supplier for
claim. I also request payment of government benefits either to myself or the party who accepts assignment below. services described below.
SIGNED SIGNATURE ON FILE DATE SIGNED
, 14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY(LMP) 15. OTHER DATE 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD YY MM DD YY MM DD YY MM DD YY
QUAL. 431 QUAL.
02 28 YY FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
17a.
MM DD YY MM DD YY
17b. NPI FROM TO
19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 20. OUTSIDE LAB? $ CHARGES
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E) 22. RESUBMISSION
ICD Ind. 0
CODE ORIGINAL REF. NO.
A. J180 B. C. D.
E. F. G. H. 23. PRIOR AUTHORIZATION NUMBER
I. J. K. L.
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
(Explain Unusual Circumstances) DAYS EPSDT
FROM TO
PLACE OF DIAGNOSIS OR Family ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS Plan QUAL. PROVIDER ID. #
PHYSICIAN OR SUPPLIER INFORMATION
1
02 28 YY 22 99223 A 175 00 1 NPI
2
03 01 YY 22 99238 A 65 00 1 NPI
3
NPI
4
NPI
5
NPI
6
NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. Rsvd for NUCC Use
(For govt. claims, see back)
111234632 30022
YES NO $ 240 00 $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING 32. SERVICE FACILITY LOCATION INFORMATION (
33. BILLING PROVIDER INFO & PH # 101 5557754 )
DEGREES OR CREDENTIALS
( I certify that the statements on the reverse apply to this bill and
CENGAGE HOSPITAL ARNOLD YOUNG MD
are made a part thereof.) 1 PROVIDER STREET 21 PROVIDER STREET
WELLSTONE NY 123451234 INJURY NY 123472347
SIGNED ARNOLD YOUNG MD DATE 030123 a. 1123456789 b. a. 0123456789 b.
NUCC Instruction Manual available at: www.nucc.org PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12)
, ANSWER KEY
BlueCross BlueShield Case 2
Required fields: 44
Primary Form
BLUECROSS BLUESHIELD
PO BOX 1121
CARRIER
HEALTH INSURANCE CLAIM FORM MEDICAL PA 123571121
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. NUMBER (For Program in Item 1)
HEALTH PLAN BLK LUNG
XWV779448358
(Medicare#) (Medicaid#) (ID#/DoD#) (Member ID#) (ID#) (ID#) (ID#)
2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE Sex 4. INSURED'S NAME (Last Name, First Name, Middle Initial)
MM DD YY
CHU, JEFFREY, A M F CHU, JEFFREY, G
02 03 2015
5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street)
103 MOUNTAIN VIEW ROAD Self Spouse Child Other 103 MOUNTAIN VIEW ROAD
CITY STATE 8. RESERVED FOR NUCC USE CITY STATE
ELM SPRINGS NY ELM SPRINGS NY
PATIENT AND INSURED INFORMATION
ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
155686789 ( ) 155686789 ( )
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER
8762145
a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH Sex
MM DD YY
Yes No M F
07 01 1978
b. RESERVED FOR NUCC USE b. AUTO ACCIDENT? PLACE (State) b. OTHER CLAIM ID (Designated by NUCC)
Yes No
c. RESERVED FOR NUCC USE c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
Yes No BLUECROSS BLUESHIELD
d. INSURANCE PLAN NAME OR PROGRAM NAME d. CLAIM CODES (Designated by NUCC) d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, complete items 9, 9a, and 9d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENTS'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary to process this payment of medical benefits to the undersigned physician or supplier for
claim. I also request payment of government benefits either to myself or the party who accepts assignment below. services described below.
SIGNED SIGNATURE ON FILE DATE SIGNED
, 14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY(LMP) 15. OTHER DATE 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD YY MM DD YY MM DD YY MM DD YY
QUAL. 431 QUAL.
03 10 YY FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
17a.
MM DD YY MM DD YY
17b. NPI FROM TO
19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 20. OUTSIDE LAB? $ CHARGES
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E) 22. RESUBMISSION
ICD Ind. 0
CODE ORIGINAL REF. NO.
A. J209 B. J310 C. D.
E. F. G. H. 23. PRIOR AUTHORIZATION NUMBER
I. J. K. L.
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
(Explain Unusual Circumstances) DAYS EPSDT
FROM TO
PLACE OF DIAGNOSIS OR Family ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS Plan QUAL. PROVIDER ID. #
PHYSICIAN OR SUPPLIER INFORMATION
1
03 10 YY 11 99212 AB 26 00 1 NPI
2
NPI
3
NPI
4
NPI
5
NPI
6
NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. Rsvd for NUCC Use
(For govt. claims, see back)
111397992 43111
YES NO $ 26 00 $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING 32. SERVICE FACILITY LOCATION INFORMATION (
33. BILLING PROVIDER INFO & PH # 101 5552923 )
DEGREES OR CREDENTIALS
( I certify that the statements on the reverse apply to this bill and
SEJAL RAJA MD
are made a part thereof.) 1 MEDICAL DRIVE
INJURY NY 123472347
SIGNED SEJAL RAJA MD DATE 030123 a. b. a. 7890123456 b.
NUCC Instruction Manual available at: www.nucc.org PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12)
