TeddyCare ClaimIQ

INTERNAL
Marcus Johnson — Billing Specialist
MJ

Claim Review — C-1001 — Maria Gonzalez

CODED ✓ — READY FOR SUBMISSION

Coded by: Amanda Rivera | Approved: Jan 15, 2025

CMS-1500 HEALTH INSURANCE CLAIM FORM

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12

1. Insurance Type
Medicare ✓
1a. Insured's ID Number
1EG4-TE5-MK72
2. Patient Name
MARIA GONZALEZ
3. Patient DOB / Sex
03/15/1968 | F
5. Patient Address
4521 Oak Lane, Austin, TX 78745
6. Patient Relationship to Insured
Self
11. Insured's Group Number
N/A (Medicare)
17. Referring Provider
N/A
21. Diagnosis or Nature of Illness or Injury
A.E11.65
B.I10
C.E11.42
24. Service Lines
DOS FromDOS ToPlaceCPTModifierDx PointerChargesUnits
01/15/202501/15/20251199214—A, B, C$187.001
25. Federal Tax ID
74-XXXXXXX
26. Patient Account Number
C-1001
31. Signature of Physician or Supplier
Dr. Sarah Chen, MD
32. Service Facility Location
Sunshine Family Medicine, 200 Medical Pkwy, Austin TX
33. Billing Provider
Sunshine Family Medicine | NPI: 1234567890
Total Charges:$187.00

Claim Scrub Results

All required fields populated
Valid ICD-10 codes (2025 code set)
Valid CPT code with correct place of service
NPI verified and active
Timely filing: within deadline
No duplicate claim detected
6/6 passed

Member Benefits Verification

Medicare Part B:Covered
Deductible:Met ✓
Expected payment:~$149.60 (80%)
Member responsibility:~$37.40 (20%)

Coding Summary

Coder:Amanda Rivera
Code changes:1 change
G62.9 → E11.42 (diabetic neuropathy)

Claim will be transmitted as 837P to Medicare via Availity clearinghouse.