Diagnosis: Chest pain

(786.59)

Services entered on a HCFA 1500 claim form

Name; Name: Birth Birthdates: Birthdates: date IDID number ID NUMBER NUMBER: Sex Mary Anyname 01/20/1969 01/20/69 01/20/69 XYZ001111 XYZooo11111 F Mary Anyname XYZ0001111 123 123 Any Any Street Street Anytown, Ark Anyplace, AR Diagnosis Procedure: 99212 93040 81003 786.59 Date of service 10/25/13 10/25/13 10/25/13 Charge $105.00 $230.00 $25.00

Total:

$360.00

Claim submitted to insurance company (Arkansas Health)

Note: This is a fictional insurance company.

Code 99212

Code 93040

Code 81003

OV

XR

LB

Marys benefit plan: PCP copayment: $20.00 Deductible: $500 Coinsurance: 20%

Note: Deductible and coinsurance do not apply to PCP visits

BENEFIT TYPES: AA- ALCOHOL ANCILLARY AT ALLERGY TESTS BE ACCIDENTAL DENTAL CA DRUG ANCILLARY DM DURABLE MEDICAL EQUIPMENT HT- HEARING TESTS IJ- INJECTIONS IM - IMMUNIZATIONS LB- LAB WORK OV- OFFICE VISIT SP - SUPPLIES

TE TISSUE EXAM

*There are several hundred benefit types, only a small sample are provided.

BENEFIT TYPES AT BE IJ IM LB OV SP TE XR INDIVIDUAL DEDUCTIBLE 500.00 DEDUCTIBLE APPLY Y

INPATIENT COPAYMENT
PCP COPAYMENT 20.00

DEDUCTIBLE APPLY N
DEDUCTIBLE APPLY N

MEMBER OUT OF POCKET

20% N

IF COPAYMENT APPLY- SHOULD COINSURANCE APPLY

BENEFIT TYPES AA CA HT INDIVIDUAL DEDUCTIBLE 500.00 DEDUCTIBLE APPLY Y

INPATIENT COPAYMENT
PCP COPAYMENT MEMBER OUT OF POCKET

N
N 20%

DEDUCTIBLE APPLY Y
DEDUCTIBLE APPLY Y

IF COPAYMENT APPLY- SHOULD COINSURANCE APPLY

Diagnosis: 786.59 OV 99212 10/25/13 XR 93040 10/25/13 LB 81003 10/25/13

$105.00 $230.00 $25.00

Total charges: $360.00 ARK HEALTH paid: $340.00 Member copay: $20.00 Check# 00004450999

BENEFIT TYPES DM INDIVIDUAL DEDUCTIBLE 500.00 DEDUCTIBLE APPLY Y

INPATIENT COPAYMENT
PCP COPAYMENT MEMBER OUT OF POCKET

N
N 20%

DEDUCTIBLE APPLY Y
DEDUCTIBLE APPLY Y

IF COPAYMENT APPLY- SHOULD COINSURANCE APPLY

Diagnosis: 719.479 DM E0130 11/10/13 $125.00

Total charges: $125.00 ARK HEALTH paid: $.00 Member deductible: $125.00 *This is one of many ways of how medical claims are coded and processed.