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