Hospital Billing 2nd Edition by Susan Magovern,Jean Jurek

Exercise 10

Fill in FLs 50-65 below for patient Leo P. Trevor, given the following insurance and patient information. The hospital's NPI is 3322100065. To date, the hospital has received $1,009.00 from Aetna toward the payment of this claim.Insurance Information
Patient Information
Primary: Aetna
Patient's Name: Leo P. Trevor
Plan ID/Carrier Code: 000007
Insured's Name: Lynn Trevor
Release of Info on File: Y
Patient Relationship to Insured: Husband
Benefits Assigned: Y
Insured's Plan ID: CJ88 2Y
Preauthorization Number: 98664H
Insurance Group Name/No: A5JJ
Provider ID: AE922VZ
Employer: Safeway
Insurance Information
Patient Information
Secondary: Medicare
Patient's Name: Leo P. Trevor
Plan ID/Carrier Code: 00308
Insured's Name: Leo P. Trevor
Release of Info on File: Y
Patient Relationship to Insured: Self
Benefits Assigned: Y
Insured's Plan ID: 197228851A
Preauthorization Number:-
Insurance Group Name/No:-
Provider ID: 070089
Employer:-
UB-04 Form - FLs 50-65
974_13_182_Q_3