HCR/202 v6 Reimbursement and Coverage Worksheet HCR/202 v6 Page 2 of 2 Reimbursement and Coverage Worksheet Resources: Ch. 8 and 12 of Medical Insurance: A Revenue Cycle Process Approach (7th ed.) Imagine you are a billing supervisor at a local health facility. You have been asked to determine the expected reimbursement and coverage determination on the following claims: 1. You reviewed the claim 1500 form for patient Kevin Luke. You realize it is a new calendar year and he had not met his deductible. You had an authorization on file for treatment. Total billed charge amount is $1,100.00. His benefits are as follows: PPO-Medical Care for diagnostic testing In-network benefit preauthorization required. Pays at 100% after deductible is met. Must meet deductible. Annual family deductible is $500. Calculate the expected reimbursement from insurance and what the patient will owe. 2. You review the claim form for Lisa Smith for treatment of hyperglycemia. You discover she received treatment from a non-network provider. She has met her annual deductible. Total charges for the date of service are $170. The plan pays at usual and customary, which is exactly what was billed. Her benefits are as follows: PPO-Medical care office visits In-network benefit-Office visit copayment: $10.00 Out-of-network deductible and coinsurance of 20%. Calculate the expected reimbursement from insurance and her coinsurance. 3. You are reviewing a claim for Maria Johnson, a 45-year-old who received a well check and flu shot from her in network provider. Her benefits are as follows: PPO-Medical Care office visits In-network benefit- copayment: Office visit $10.00 and Injections $25.00 Out-of-network Deductible and Coinsurance of 20%. Mrs. Johnson called the office because she thought she had overpaid during her visit. What was Mrs. Johnson’s copay the date of the visit? 4. You are reviewing the vision exam benefits for Zach Bergman. He presented for an eye exam stating he needed new glasses. He had an examination 13 months prior and notes he can have an exam every year. His benefits are as follows: PPO-Medical care office visits In-network benefit-One vision exam every 2 calendar years. Out-of-network Deductible and Coinsurance of 20%. Covered every 2 calendar years. What is Mr. Bergman’s benefit? 5. Lisa Smith called your office noting she had to be transported to the hospital by ambulance while on vacation for food poisoning. She was concerned about what she will need to pay out-of-pocket. She was not admitted. Her benefits for emergency treatment are as follows: PPO-Emergency treatment In-network benefit-Copay $100. Waived if admitted. Ambulance services no charge. Out-of-network Copay $100. Waived if admitted. Ambulance services no charge. What should Lisa Smith expect to pay out-of-pocket? Part B: Insurance Process Discussion Choose one of the above cases and imagine the following scenario: 1. You received a call ...

1. HCR/202 v6
Reimbursement and Coverage Worksheet
HCR/202 v6
Page 2 of 2
Reimbursement and Coverage Worksheet
Resources: Ch. 8 and 12 of
Medical Insurance: A Revenue Cycle Process Approach
(7th ed.)
Imagine you are a billing supervisor at a local health facility.
You have been asked to determine the expected reimbursement
and coverage determination on the following claims:
1. You reviewed the claim 1500 form for patient Kevin Luke.
You realize it is a new calendar year and he had not met his
deductible. You had an authorization on file for treatment. Total
billed charge amount is $1,100.00. His benefits are as follows:
PPO-Medical Care for diagnostic testing
In-network benefit preauthorization required. Pays at 100%
after deductible is met.
Must meet deductible. Annual family deductible is $500.
Calculate the expected reimbursement from insurance and what
the patient will owe.
2. You review the claim form for Lisa Smith for treatment of
hyperglycemia. You discover she received treatment from a
non-network provider. She has met her annual deductible. Total
charges for the date of service are $170. The plan pays at usual
and customary, which is exactly what was billed. Her benefits
are as follows:
PPO-Medical care office visits

2. In-network benefit-Office visit copayment: $10.00
Out-of-network deductible and coinsurance of 20%.
Calculate the expected reimbursement from insurance and her
coinsurance.
3. You are reviewing a claim for Maria Johnson, a 45-year-old
who received a well check and flu shot from her in network
provider. Her benefits are as follows:
PPO-Medical Care office visits
In-network benefit- copayment: Office visit $10.00 and
Injections $25.00
Out-of-network Deductible and Coinsurance of 20%.
Mrs. Johnson called the office because she thought she had
overpaid during her visit. What was Mrs. Johnson’s copay the
date of the visit?
4. You are reviewing the vision exam benefits for Zach
Bergman. He presented for an eye exam stating he needed new
glasses. He had an examination 13 months prior and notes he
can have an exam every year. His benefits are as follows:
PPO-Medical care office visits
In-network benefit-One vision exam every 2 calendar years.
Out-of-network Deductible and Coinsurance of 20%. Covered
every 2 calendar years.
What is Mr. Bergman’s benefit?
5. Lisa Smith called your office noting she had to be transported
to the hospital by ambulance while on vacation for food
poisoning. She was concerned about what she will need to pay
out-of-pocket. She was not admitted. Her benefits for
emergency treatment are as follows:
PPO-Emergency treatment
In-network benefit-Copay $100. Waived if admitted. Ambulance

3. services no charge.
Out-of-network Copay $100. Waived if admitted. Ambulance
services no charge.
What should Lisa Smith expect to pay out-of-pocket?
Part B: Insurance Process Discussion
Choose one of the above cases and imagine the following
scenario:
1. You received a call from the patient concerning their bill, and
they would like to discuss it with you. You were asked a series
of questions concerning insurance processes and medical
reimbursement by the patient. As the billing expert you have a
conversation addressing the patient’s billing questions and
explaining the insurance process and steps you take. In 175 to
350 words, create a conversational dialog with the patient
explaining the insurance process and why their claim was paid
the way it was paid. Your conversation should include:
· Explain how and why the patient’s insurance is verified.
· Explain how to interpret the patient’s benefits for
reimbursement using details from your selected case.
· Explain possible pending insurance or patient actions relevant
to your selected case.
· Apply a professional and customer-oriented introduction and
closure to the dialog.
Copyright© 2019 by University of Phoenix. All rights reserved.
Copyright© 2019 by University of Phoenix. All rights reserved.
image1.png
SOAP NOTE
Name: C. P
Date: 09/6/18
Time: 2:00 PM
Age: 52 y/o

4. Sex: Male
SUBJECTIVE
CC: “I am here because my right elbow hurts”
HPI: C. P. is a 52-year-old male, who comes to the office today
complaining of a two months’ history of pain in his right elbow.
At the beginning, the pain was mild and slowly it worsens. He
describes the pain burning sensation that is located on the outer
part of his right elbow accompanied of weak grip strength and is
an 8 on a scale of 0 -10. Denies the pain radiating. He stated
that the pain is worsened with forearm activity, such as shaking
hands or holding a racquet. The patient states that has taken
acetaminophen every 4-6 hours to alleviate the pain. Denies any
other past medical history.
Medications: Denies any herbal medicine.
Acetaminophen Tab 325 mg 2-tab PO every 4-6 hours for pain
PMH:
Allergies: Denies any allergies to food or medication
Medication Intolerances: Denies.
Chronic Illnesses/Major traumas: Patient don’t have a
significant medical history. The patient denies traumas
Hospitalizations/Surgeries:Denies hospitalizations
Other:
Immunizations: Immunizations currently up to date. Flu shot in
this year (2018) and Tetanus booster vaccine in 2016.
Environmental hazard: Patient denies any environmental hazard.
Safety measure: Patient state “I always use my belt car.”
Exercise and leisure: Patient perform exercises two or three
times a week. Walk everyday
Sleep: Patient has no difficulty with sleeping. Usually go to bed
at 22 00 pm and wake up at 6 00 am.
Diet: Drink one to three cup of coffee a day. Otherwise, drink 2
liters of water 24 hours recall Breakfast with coffee milk and

5. bread. Snacks. Lunch: Rice with some meat, fish or eggs.
Dinner: variable
Family History
Mother: Alive, (78 years old) Hypercholesterolemia. Diabetes
type II
Father: Alive, (80 years old) HTN, CHF
Paternal Grandfather deceased (98 years) stroke
No family history of cancer or genetic disorders reported
Social History:
Education level: University
Occupational history: Teller in a bank.
Current living situation/partner/marital status: Lives in a house
in Miami, Florida with his wife. Sexually active. Denies STI's
Substance use/abuse: Alcohol (1 cup of wine only weekends),
Denies tobacco and illegal drugs uses.
Nutritional Hx: Well nourished.
ROS
General
Negative for chills and malaise, sweats, chest pain anorexia,
fatigue, hair loss, weakness, rash, bleeding, weight loss, weight
gain.
Cardiovascular
Negative for chest pain, palpitations murmur, bruits or edemas.
Skin
Negative for cyanosis, ulcers, bruising, rash or abnormalities in
nails or hair.
Respiratory
Negative for cough, dyspnea, and other respiratory symptoms.
Denies pneumonia, TB
Eyes
Denies changes in vision, no blurred vision, no diplopia, no

6. tearing, no scotomata, and no pain.
Gastrointestinal
Negative for nauseas, emesis, dysphagia, bowel habit changes,
melena, and constipation.
Ears
Denies ear pain, hearing loss, ringing in ears, discharge, pearly
grey membranes.
Genitourinary/Gynecological
Denies urgency, frequency burning, change in color of urine,
STDS. Patient denies burning on urination or discomfort.
Nose/Mouth/Throat
Denies difficulty in smelling, sinus problems, nose bleeds or
discharge. Denies dysphagia, hoarseness, or throat pain.
Musculoskeletal
Positive for burning pain localized on the outer part of his
elbows accompanied of weak grip strength, denies radiation.
Negative for back pain, joint swelling, stiffness, fall, traumas,
fracture, and osteoporosis.
Breast
Deferred
Neurological
Negative for headaches. Negative for Syncope, seizures, No
paralysis, paresthesias, no changes in mentation, no ataxia
Heme/Lymph/Endo
Negative for bruising, night sweats, swollen glands, increase
hunger, thirst, cold or heat intolerance. Negative for
lymphadenopathy
Psychiatric
Negative for anxiety, sleeping disturbed, depression and
suicidal ideation.
OBJECTIVE
Weight: 186 lbs.
BMI: 23.9
Temp 98.4 F

7. BP 122/75 mm/Hg
Pain: 8/10
Height 6’2’’ inch
Pulse 74 bpm
Resp 20 bpm
O2 Saturation: 99 %
General Appearance
Patient is a 52 y/o Hispanic male. Appearing of staged age.
Alert and oriented; answers questions appropriately. Patient
looks sick. No acute distress at this time. AAOX4, PERRLA;
answers questions appropriately.
Skin
Skin is white, warm, dry, clean and intact. No rashes or lesions
noted.
HEENT
Deferred
Cardiovascular
RRR S1, S2 with regular rate and rhythm with no murmurs. No
extra sounds, clicks, thrill or bruits. PMI 5TH ICS, MDL.
Capillary refill < 3 seconds. Pulses 2+. No edemas.
Respiratory
Symmetric chest wall with good expansion, normal-shaped
chest. Respiration even and unlabored, depth normal. Lung
resonant. No fremitus. Bilateral breath sounds clear upon
auscultation. No wheezing, rhonchi sound. No adventitious
sound noted.
Gastrointestinal
Deferred
Breast
Deferred
Genitourinary
Deferred
Musculoskeletal
Point tenderness at ECRB insertion into lateral epicondyle, few
mm distal to tip of lateral epicondyle. Decreased grip strength.
Resisted wrist extension with elbow fully extended, resisted

8. extension of the longs fingers, maximal flexion of the wrist and
passive wrist flexion in pronation causes pain at the elbow.
Neurological
Speech clear. Good tone. Posture erect. Balance stable; normal
gait.
Reflexes 2+ bilaterally throughout.
CN II-XII intact.
Psychiatric
Good judgment. Alert and oriented. Dressed in clean skirt and
blouse. Maintains eye contact. Speech is soft, though clear and
of normal rate and cadence; answers questions appropriately.
Lab test: None
Imaging: No imaging is required for initial evaluation and
treatment. (Domino, Baldor, Golding, and Stephens, 2017).
Special Tests
Electromyography in patient with neurologic deficits. US and
MRI are useful to evaluate the ulnar collateral ligament and to
diagnose traumatic tears to flexor pronator origin of the
epicondyle; consider these imaging tests if there is no
improvement in the patient’s condition after conservative
therapy (Not necessary at this time) (Domino et al., 2017).
Diagnosis
Differential diagnostic:
1. Elbow Osteoarthritis: Osteoarthritis can affect the joints
anywhere in the body, including the elbow. Symptoms include:
Feeling of crunching movement of the knee due to damage to
the cartilage, blockage of the elbow joint, due to lose fragments
of cartilage or bone, swelling in the elbow as the disease
progresses and tingling, caused by pressure exerted on the ulnar
nerve as a result of the swelling (AAOS, 2017).
2. Epicondylar fractures: Symptoms of a fractured elbow
include: Severe and acute pain. The patient may complain of
numbness in the hand if he has a nerve injury. When examining
the patient there is pain on palpation, inflammation, bruising,
limited movement (Buttaro, Trybulski, Bailey, & Sandberg-

9. Cook, 2017).
3. Ulnar neuropathy: The Ulnar Neuropathy known as Cubital
Compression Syndrome in the epitrochlear-olecranon conduit,
the majority of the cases is of unknown or idiopathic origin.
There are predisposing factors, such as working with the elbow
flexed and supported (computer), elbow fractures, tumors or
metabolic diseases (diabetes, alcoholism, among others).
Symptoms include: Pain in part antero-medial elbow and
forearm, can there are paresthesia in the last two fingers.
Hypoesthesia in the cubital distribution area is related to
repeated movements of the elbow. Symptoms usually improve
when the elbow is extended ( Dy & Mackinnon, 2016).
Presumptive Diagnosis: Lateral epicondylitis, right elbow
(M77.11): It is a tendinopathy of the elbow characterized by
pain and tenderness at the origins of the wrist flexors/ extensors
at the humeral epicondyles. May be acute or chronic. Usually
involved dominant arm. Risk factors included repetitive wrist
motions. smoking. Obesity. Upper extremity forceful activities
(Domino et al., 2017).
Plan/Therapeutics & Education:
Further testing: None
Medication: Diclofenac Sodium Tab/75 mg take 1-tab PO TID x
7 days. Diclofenac sodium 1 % gel: apply a thin film to the
affected area TID
Non-medication: Ice therapy. Use counterforce bracing with a
forearm strap in the area of the muscle mass of the proximal
portion of the forearm can be helpful. Encourage relative rest
Modalities, such as massage, ultrasound therapy, and electrical
stimulation may be helpful
Patient education: Avoid playing tennis for several weeks.
Consultation/Collaboration: No referral needed at this time.
Follow up:
Follow up in one month to determine treatment effectiveness
and to assess whether referral to specialist is warranted.

10. References
AAOS. (2017). Osteoarthritis of the Elbow. Retrieve from
https://orthoinfo.aaos.org/en/diseases--conditions/osteoarthritis-
of-the-elbow/
Buttaro, T., Trybulski, J., Bailey, P., & Sandberg-Cook, J.
(2017). Primary care. A collaborative practice. (5th ed.). St
Louis, MO: Elsevier
Bickley, L. S., & Szilagyi, P. G. (2017). Bates’ guide to
physical examination and history taking (12th ed.).
Philadelphia, PA: Wolters Kluwer/Lippincott, Williams, and
Wilkins
Domino, F. J., Baldor, R. A., Golding, J., & Stephens, M. B.
(2017). The 5-minute clinical consult 2017. (25th ed.)
Philadelphia, PA: Wolters Kluwer
Dy, C. J., & Mackinnon, S. E. (2016). Ulnar neuropathy:
evaluation and management. Current Reviews in
Musculoskeletal Medicine, 9(2), 178–184.
http://doi.org/10.1007/s12178-016-9327-x
Goolsby, M. J., & Grubbs, L. (2015). Advanced assessment:
Interpreting findings and formulating differential diagnoses ( 3rd
ed.). [VitalSource Bookshelf]. Retrieved from
https://digitalbookshelf.southuniversity.edu
ICD10. (2018). Retrieve from
https://www.icd10data.com/search?