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