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- Sample Statement
Advance Beneficiary Notice (ABN):
A form signed by the patient before certain services are rendered, notifying patient that Medicare may not cover this service, and they will be responsible for payment. The ABN was previously called the Medicare Medical Necessity Waiver.
Requirement of your insurance company to determine medical necessity for services rendered. Authorization does not guarantee benefits for payment. Benefits are based on policy provisions in force at the time services are rendered. Questions about authorization requirements in your contract should be directed to your insurance plan.
An amount established by your insurance company as your responsibility of billed fees.
An amount determined by the insurance company to be paid on an annual basis before any benefits are paid.
Any service that is not emergency care.
Explanation of Benefits (EOB):
A document provided by the patient's insurance plan or Medicare detailing how benefits are processed and paid for services rendered.
The facility is contracted with the insurance company and has agreed to a specified reimbursement schedule.
A service not covered under the limits of the patient's health insurance. These amounts are the patient's responsibility to pay. Patients should direct questions about coverage to their health plan.
Out of Network:
The facility is not contracted with the insurance company. No agreement is in place for a specific reimbursement amount. PPO insurance companies generally charge a higher deductible and co-payment for this service. In addition, they may use a "usual and customary" fee schedule for payment purposes. The difference between the usual and customary amount and the facility charge is the responsibility of the patient to pay. If the insurance company is an HMO only emergency services are permitted to be performed at an out of network facility.
Areas in the lobbies of the hospital where patients fill out their financial paperwork. We will confirm your address, phone, and insurance information. We will then provide a patient identification band that you will need for your services.
Health claim form sent to the primary or secondary insurance carrier.
Usual and Customary (UCR):
Predetermined allowable limits used by insurance carriers to limit the maximum amount they pay on a given service. Memorial does not honor usual and customary reductions.