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