TPL BCBS $1,340 Duration Reviewed by pt for accurate info Payer Medicare Medicare Part A Introduce Referral 501r Pre- Admit 06 HIPAA DOB Pull Method MOON Confine Guarantor Patient 11 05 Birthday Rule HAR Age Ineligible Deposit Financial Responsibility Form SSN MSPQ HAR Patient Class Medicare Part C Room RUBA Active Thank You Medicaid Name DOB SSN Encounter Coverage COB Pending Copay RCO Deductible Check- in People 65 or older Disabled ESRD Payment Access Fin Resp for Non- Covered ABN Check- out CSN AGB Address Benefits TPL BCBS $1,340 Duration Reviewed by pt for accurate info Payer Medicare Medicare Part A Introduce Referral 501r Pre- Admit 06 HIPAA DOB Pull Method MOON Confine Guarantor Patient 11 05 Birthday Rule HAR Age Ineligible Deposit Financial Responsibility Form SSN MSPQ HAR Patient Class Medicare Part C Room RUBA Active Thank You Medicaid Name DOB SSN Encounter Coverage COB Pending Copay RCO Deductible Check- in People 65 or older Disabled ESRD Payment Access Fin Resp for Non- Covered ABN Check- out CSN AGB Address Benefits
(Print)
TPL
BCBS
$1,340
Duration
Reviewed by pt for accurate info
Payer
Medicare
Medicare Part A
Introduce
Referral
501r
Pre-Admit
06
HIPAA
DOB
Pull Method
MOON
Confine
Guarantor
Patient
11
05
Birthday Rule
HAR
Age
Ineligible
Deposit
Financial Responsibility Form
SSN
MSPQ
HAR
Patient Class
Medicare Part C
Room
RUBA
Active
Thank You
Medicaid
Name
DOB
SSN
Encounter
Coverage
COB
Pending
Copay
RCO
Deductible
Check-in
People 65 or older
Disabled
ESRD
Payment
Access
Fin Resp for Non-Covered
ABN
Check-out
CSN
AGB
Address
Benefits
