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