accident: some examples of types of accidents for which the patient is being treated are the following: motor vehicle accident, accident that occurred in the patient’s own home, accident victim of a crime , accident at someone else’s house, accident in a public place, drowning accident, work accident, self-inflicted accident, accident with third parties involved.
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occupational accident: answer if the patient’s accident was occupational. Allowable values for this field are as follows: Yes, the patient’s accident was work-related. no, the patient’s accident was not work related.
address: fill in the postal address. approved abbreviations are: n – north e- east s- south w- west ln – lane wy - way pkwy – parkway blvd – boulevard apt- apartment pl – place sp- space rr – rural route st- street rt – route ave- avenue post office box – post office box rd- street # – number
Admitting Physician: The name of the physician responsible for admitting the patient to a hospital or other inpatient facility.
Advance Directive: Written in advance, an advance health care directive is a written document that says how a patient wants medical decisions made if they lose the ability to make decisions for themselves. An advance health care directive can include a living will and durable power of attorney for health care.
beneficiary: the name of a person who has health insurance through medicare or an insurance plan.
Date of Birth: Depending on which section you are answering this question in, enter the patient, guarantor, or subscriber’s date of birth in American mm/dd/yyyy format, where mm is the month of birth. birth, dd is the day of birth, and yyyy is the year of birth. Insurance priority is sometimes determined in order of date of birth in the calendar year.
city: enter the name of the city that is part of the postal address.
coordination period (30-month coordination period): a period of time in which the patient’s health care bills will be paid first by the employer’s group health plan and Medicare will pay second place. If the employer group health plan does not pay 100% of the patient’s health care bills during the coordination period, Medicare may pay the remaining costs.
country: enter the name of the country that is part of the postal address. You don’t need to answer this for US addresses. uu. united states of america.
Date or time of injury or accident: Enter the date of the patient’s accident. if a date is entered, the time of the accident must also be entered. Enter the date of the accident in mm/dd/yyyy format, where mm is the month, dd is the day, and yyyy is the year. enter the time of the accident in hh:mm format, where hh is the hour and mm is the minute.
Description of injury/illness: Describe the accident in a written report, answering what happened? Was it a fall, was the patient hit by a person, an object, or a vehicle? What part(s) of the body was(were) injured? where was the patient’s accident site? home, work*, school*, public street, restaurant*, workplace* and retail store* are examples of locations. *must include the actual name and address of the facility or site.
diagnosis: the name that describes the health problem the patient has or is seeking treatment for. the reason the patient is being treated.
end-stage renal disease (esrd) permanent kidney failure that is severe enough to require lifelong kidney dialysis or a kidney transplant.
employer group health plan (ghp): a ghp is a health plan that provides health coverage to employees, former employees, and their families, and is supported by an employer or an organization of employees.
Employment Status: Depending on which section you are answering this question in, identify the employment status of the patient, underwriter, or guarantor. employed full-time, employed part-time, unemployed, self-employed, retired, active duty military.
entitlement: the reason the patient became eligible for medicare benefits. the reason may be age, disability, or end-stage renal disease.
ethnicity: character, origin or ethnic affiliation. an ethnic group belonging to or relating to a sizeable group of persons who share a common and distinctive racial, national, religious, linguistic, or cultural heritage.
name: Depending on the section in which you answer this question, enter the name of the patient, guarantor, or subscriber. this name should be the full legal name rather than a personal preference, nickname, or initial.
Gender: Enter the person’s gender or sex. the allowed values are the following: m – masculine f – feminine
Group Name:Enter the name of the group or insurance plan defined for the patient account. refer to the insurance card for this information. responses for this field can include letters, numbers, and spaces.
Group Number: Enter the identification number or code used for group coverage by the company or administration to identify the patient’s insurance group. refer to the insurance card for this information. the answer can include letters, numbers, and spaces.
guarantor: the person who ultimately accepts financial responsibility for paying the patient’s bill. in most cases it is the adult patient who receives the service. if the patient is a child, the responsible party may be the child’s parent or legal guardian. the guarantor should not be confused with the underwriter of the insurance. this may or may not be the same person.
accidental injury or illness: some examples of types of accidents for which the patient is being treated are: motor vehicle accident, accident in the patient’s own home, accident – victim of a crime, accident in someone else’s house, accident in a public place, drowning accident, work accident, self-inflicted accident, accident with third parties involved.
inpatient/outpatient/maternity procedure: answer hospitalization if your doctor has told you that you will stay in a hospital bed for one or more days. answer ambulatory if the service requires a stay of less than 24 hours or is performed in an outpatient department. answer maternity if this procedure is related to the delivery of a newborn baby.
Insurance Information: The policy/claim number, plan group number, and group name can be found on the insurance subscriber’s insurance card.
Insurance Name: Enter the name of the insurance company that issued the policy. refer to the insurance card for this information. It is usually found on the back of the insurance card where claims are submitted.
Last Menstrual Period: The date your last period started. this is used to calculate your due date and the date from which your 40 weeks of pregnancy officially begin.
last name: Depending on which section you are answering this question in, enter the last name of the patient, guarantor, or underwriter. this name must be the full legal last name rather than a personal preference, nickname, or initial. examples: mc donald = mcdonald (no space) o’brien = obrien (no apostrophe, no space) smith-jones = smith jones (use a space, not a hyphen) st. james = st james (don’t use period)
Maiden Name: Enter the maiden name of a married patient. this name should be the full legal last name rather than a personal preference, nickname, or initial.
Marital Status: Enter the patient’s marital status, for example: Single, Married, Separated, Divorced.
materials you may need to complete registration: all applicable health insurance cards or documents that include the name of the insurance company, insurance policy number, and billing address insurance and insurance phone numbers. dates of birth, names, mailing addresses of residents, and telephone numbers of the patient, subscriber, and guarantor. Employer names, employer addresses, and employer phone numbers for the patient, subscriber, and guarantor. name, address, and phone number of the person who is the primary/emergency contact for the patient.
medicare: A federal health insurance program for the elderly, totally disabled, and those with end-stage renal disease. benefits provided under title xviii of the united states social security act of 1965, as amended from time to time. Medicare Part A pays for hospital services. Medicare Part B is the voluntary part of Medicare that pays a percentage of reasonable and customary costs for medical and ancillary services.
medicare hmo: a type of medicare managed care plan where a group of doctors, hospitals, and other health care providers agree to provide medical care to medicare beneficiaries for a fixed amount of Medicare money each month. In an HMO (health maintenance organization), the beneficiary generally must get all of his or her care from providers that are part of the plan. there may be restrictions where the beneficiary can only go to certain hospitals or doctors. an alternative to the original medicare plan that replaces the original medicare plan and is often called senior plans after the name of the insurance.
Medicare Managed Care Plan: These are health care options (like HMOS) in some areas of the country. In most plans, the beneficiary can only go to doctors, specialists or hospitals on the plan’s list. plans must cover all medical care under medicare parts a and b. some plans cover extras, like prescription drugs. costs may be lower than in the original medicare plan. an alternative to the original medicare plan that replaces the original medicare plan and are often called senior plans after the name of the insurance.
medicare private fee-for-service plans. a private insurance plan that accepts people with medicare. They can go to any Medicare-approved doctor or hospital that accepts the plan’s payment. The insurance plan, rather than the Medicare program, decides how much it will pay and how much the beneficiary will pay for the services you receive. the beneficiary may pay more for benefits covered by medicare. they may have extra benefits that the original medicare plan doesn’t cover. an alternative to the original medicare plan that replaces the original medicare plan and are often called senior plans after the name of the insurance.
Medicare Plan (Original): (sometimes called Fee-for-Service): Anyone with Medicare can join the Original Medicare Plan. This plan is available nationwide. A pay-per-visit health plan that allows a covered patient to go to any doctor, hospital, or other health care provider that accepts Medicare. you must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). The original Medicare plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).
medicare part a: hospital insurance that pays for inpatient hospital care, critical access hospitals, skilled nursing facilities, hospice care, and some home health care.
Medicare Part B: Health insurance that helps pay for outpatient hospital care, doctor services, and some other medical services that Part A doesn’t cover, like physical and occupational therapy, and some home health care. home health. Medicare or surgical care that Medicare Part B helps pay for and does not include an overnight hospital stay, including: blood transfusions; certain drugs; laboratory tests billed by the hospital; mental health care; medical supplies such as splints and casts; emergency room or outpatient clinic, including same-day surgery; and emergency room or outpatient clinic, including same-day surgery; and x-rays and other radiation services.
msp/medicare secondary payer: medicare questionnaire: questions required by the hospital provider’s agreement with medicare to ask all medicare beneficiaries at each inpatient and outpatient admission. To comply with law and regulation, the provider (hospital) must verify information from the MSP before submitting a bill to Medicare. it is a guide to identifying other payers that may be primary for medicare. Starting with part 1, answer each question in sequence. comply with the instructions that follow an answer. if the instructions tell you to go to another part, answer, in sequence, each question in the new part.
medicare + choice plans (pronounced “medicare plus choice”). a medicare program that gives the patient more choices among health plans. everyone with medicare parts a and b is eligible, except those with end-stage renal disease. There are two types of Medicare + Choice plans. Medicare + Choice plans are offered by private (Medicare-approved) insurance companies that provide care under contract with Medicare. medicare + choice plans include: 1. medicare managed care plan and 2. medicare private fee-for-service plans. an alternative to the original medicare plan that replaces the original medicare plan and are often called senior plans after the name of the insurance.
msp provision: This question applies if the patient has dual coverage (ie, entitlement based on age and esrd or disability and esrd) and the initial entitlement was age or disability.
- if a ghp was primary the day before they became esrd eligible, choose yes and the ghp will remain primary for the 30-month coordination period.
- yes medicare was primary, the day before the patient became eligible for medicare based on esrd, then medicare is primary.
Submitter Name: Enter the name of the person submitting the form, if you are completing it on behalf of someone else.
newborn pediatrician: a doctor specializing in the branch of medicine that deals with the care of infants and children and the treatment of their illnesses.
Occupation: Depending on the section in which you answer this question, enter the occupation or title of the patient, guarantor or underwriter. enter a specific occupation, such as teacher, doctor, carpenter, etc. housewife and student are valid occupations. enter the name and address of the student’s school in the employer field. freelancers must include their type of work.
Patient’s Relationship to Subscriber: This field contains a code that indicates the patient’s relationship to the subscriber. the underwriter is the person who underwrites or carries the insurance plan for the patient’s case. How does the patient relate to the subscriber? for example, if the subscriber is the mother of the patient, then the relationship of the patient to the subscriber is child. answer: how does the patient relate to the subscriber? the patient is the subscriber’s child. allowed values are: child, parent, stepchild, patient is insured (has insurance on himself), foster child, grandparent, grandchild, spouse, ward of court, other.
Phone Number: Enter the phone number requested in the question, including the three-digit area code prefix associated with the phone number and the seven-digit phone number. for international phone numbers, include the country code and city (routing) code in front of the actual phone number.
Policy Number: Enter the policy number of the patient’s insurance plan. refer to the insurance card for this information. For Medicare plans, enter the patient’s Medicare number. for all other plans, enter the policy number of the insurance plan. the answer can include letters, numbers, and spaces.
Primary Care Physician/Personal Care Physician: In an HMO plan, the PCP is responsible for providing covered health care services and coordinating referrals to other network providers when needed. require specialized care. The PCP may be trained in family practice, internal medicine, pediatrics, or general medicine.
Primary Insurance or Primary Payer: An insurance policy, plan, or program that pays first on a claim or hospital bill for medical care. it could be medicare or other commercial health insurance.
Primary Language: What is the patient’s primary language? enter another language if you prefer some documents to be provided in this language.
previous admission date: enter the admission date of the patient’s last hospitalization. the day the patient began their last hospital stay.
Previous discharge date: Enter the discharge date of the patient’s last hospital stay. the day the patient went home after their last hospital stay.
Previous Hospital:Enter the name of the hospital where the patient has been admitted just prior to this visit.
previous stay: has the patient been admitted to a hospital before? If yes, please provide the name of the most recent facility and the dates of admission and discharge from that facility.
procedure: something done to solve a health problem or to get more information about it. for example, surgery, tests, and placement of an intravenous (iv) line are procedures.
procedure authorization: agreement by the insurance company to pay for medical services. doctors and hospitals request this approval from the insurance company before providing medical services. failure to obtain approval often results in a penalty for the patient, as services may not be covered by insurance.
procedure date: enter the date of the appointment you have been given for the procedure. the date must be entered in mm/dd/yyyy format.
procedure time: enter the appointment time you have been given for your procedure to be performed.
provider: a doctor, hospital, health professional, or health care facility.
Referral: An authorization from the patient’s primary care physician to see a specialist or receive certain services. In many managed care plans, the patient needs to obtain a referral before receiving care from someone other than their primary care physician. If you don’t get a referral first, the plan may not pay for your care.
refresh: Refreshing the pre-registration web page will reset the timer to the allotted amount of time to complete the form. the time given to fill out the pre-registration form is 24 minutes. Please note that refreshing a page will erase any data that has already been entered on the page! A web page can be refreshed in several ways; by clicking the refresh icon (usually located at the top of your browser), the f5 key on your keyboard, or in internet explorer or netscape browsers by clicking the view menu and then refresh.
Relationship to Patient: Enter the relationship of the primary or emergency contact to the patient. allowed values are: mother, brother, father, friend, spouse, grandparent, emancipated minor, child, legal guardian, grandchild, other
Religion: Enter the patient’s religious preference.
Required Answers/Fields: Required fields are indicated by an asterisk to the left of the field description. an answer must be entered for each of these fields. the information is necessary for online pre-registration. if you do not have the required information, please collect the information before proceeding. the computer will not send the record without this data.
Insurance or Secondary Payer: An insurance policy, plan, or program that secondarily pays a claim or hospital bill for medical care. this could be medicare, medicaid or other health insurance depending on the situation.
Social Security Number: Allowed values are the 9 numbers that make up a valid Social Security Number or a valid Railroad Retirement Number.
state: enter the full name of the state (for the united states) or province (for canada).
Submitter Phone Number: The phone number of the person submitting the form. this should be the best number to reach the subimtter be it mobile, home, work or other. enter the three-digit area code prefix associated with the phone number and the seven-digit phone number. for international phone numbers, include the country code and city (routing) code in front of the actual phone number.
Sender’s Relationship to Patient: What is your relationship to the patient (eg, spouse, child, friend, caregiver, etc.)?
subscriber: the person who signs and is responsible for a contract with a health insurance plan. the underwriter is the person who underwrites the insurance plan for the patient’s case. the subscriber is different from the affiliate, which is defined as any person covered by the contract.
type of procedure: something done to fix a health problem or to get more information about it. for example, surgery, tests, and placement of an intravenous (iv) line are procedures.
Type of Outpatient Service: Select the type of procedure you are seeking services for, whether you are admitted for inpatient or outpatient care.
worker’s compensation: insurance that employers are required to carry to cover employees who become ill or injured on the job while performing work-related tasks.
zip code or zip code: Enter the zip code. if the zip code is for a u.s. state or possession, zip code must be numeric. if the postal code is for a Canadian province, the postal code must be six characters long and the last character must be a number.