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