Mission Charity Care Response April 30, 2020

Attachment A
Charity Care Policy

DEPARTMENT: POLICY DESCRIPTION:
Vendor Collections Management Charity Financial Assistance Policy for Uninsured and
Underinsured Patients
PAGE: 1 of 6 REPLACES POLICY DATED:
APPROVED: RETIRED:
EFFECTIVE DATE: 11/01/ 2017 REFERENCE NUMBER: PARA.PP.VCM.016
SCOPE:
All SSC and Facility areas responsible for requesting and evaluating Financial Assistance
Applications ("FAA") for the purposes of processing a charity write-off for certain patients receiving
services at HCA-affiliated, non-partnership, acute-care hospitals ("Hospitals").
PURPOSE:
To define the policy for providing partial or full financial relief to patients who (i) have received
emergency services, (ii) meet certain income requirements, (iii) do not qualify for state or federal
assistance for the date of service, (iv) are uninsured or underinsured, and (v) are unable to make
partial or full payment on outstanding balances. In addition, with respect to the FAA and income
validation, to establish protocols and supporting documentation requirements.
POLICY:
The following types of patients may qualify for a charity write-off based on the patient’s total
household income, supporting income verification documentation or processes, as required, and the
amount of the patient liability:
1) To be eligible for a charity write-off review, a patient must have incurred emergent, non-
elective services.
2) To be eligible for a charity write-off, a patient must be (a) uninsured or underinsured and (b)
have an out-of-pocket patient responsibility of $1,500 or more for an individual account.
Upon request by a patient and, if there are extenuating circumstances, accounts with out-of-
pocket responsibility balances of less than $1,500 may be reviewed and a charity write-off
applied if Federal Poverty Guidelines/Level ("FPL") thresholds are met as set forth in Section
9, below.
3) For purposes of this policy, an uninsured patient is one (i) with no third party payer coverage
for emergent health care services, (ii) who provides documentation that the patient is unable
to pay for some or all of the provided non-elective hospital services and (iii) who satisfies the
financial eligibility criteria set forth herein.
4) For purposes of this policy, an underinsured patient is one with some form of third party payer
coverage for health care services, but such coverage is insufficient to pay the current bill such
that the patient retains a patient liability that they are unable to pay.
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5) A validation will be completed, as required in this Policy, to ensure that if any portion of the
patient's medical services can be paid by any federal or state governmental health care
program (e.g., Medicare, Medicaid, Tricare, Medicare secondary payer), private insurance
company, or other private, non-governmental third-party payer, that the payment has been
received and posted to the account. No charity write-off can be applied to any account with
any outstanding payer liability.
6) Supporting Income Verification Documentation & Review:
A. Medicare Accounts
i. All Medicare patients (i.e., inpatients and/or outpatients) must submit supporting
income verification documentation. Electronic validation of patient income, e.g., Experian,
alone is not sufficient. Medicare requires independent income and resource verification for
a charity care determination with respect to Medicare beneficiaries (PRM-I § 312).
ii. In addition to the FAA, the preferred income documentation will be the most current
year’s Federal Tax Return. Any patient/responsible party unable to provide his/her most
recent Federal Tax Return may provide two pieces of supporting documentation from the
following list to meet this income verification requirement:
 State Income Tax Return for the most current year
 Supporting W-2
 Supporting 1099’s
 Copies of all bank statements for last 3 months
 Most recent bank and broker statements listed in the Federal Tax Return
 Current credit report
 Qualified Medicare Benefits (“QMB”) for inpatients only
iii. Dual-Eligible Beneficiaries: A Medicare beneficiary who also qualifies for Medicaid
(dual-eligible beneficiary) may be deemed indigent as long as the “Must Bill”
requirements are met. That these requirements are met must be supported by a State
Medicaid remittance advice. When claiming an amount as Medicare Bad Debt for a dual-
eligible beneficiary, Medicaid must be billed. In addition, the remittance advice showing
non-payment must be maintained as supporting documentation for the Medicare Bad
Debt adjustment. Charity write-offs for Medicaid Exhausted beneficiaries may be less
than $1,500.
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B. Non-Medicare Accounts
i. Generally, for all non-Medicare Accounts, the following will be acceptable
supporting documentation: (i) the documentation listed in A. above, (ii) or any one
of the following:
 Most Recent Employer Pay Stubs

 Written documentation from income sources
 Proof of Medicaid Eligibility
 Electronic validation of patient income and family size, such as Experian
ii. Supporting income verification documentation through an electronic validation of

patient information/income, such as Experian, shall be obtained where no other
income verification is obtained.
iii. To the extent required by state law, a complete FAA shall be obtained for any
dollars reported as charity to the state.
iv. Review of assets may take place during the application process where required by
state law or regulation.
C. Patients/Responsible Party Deemed Eligible.
The patient/responsible party may be deemed to meet the charity guidelines if:
 the patient/responsible party is determined to be eligible by a local clinic under
poverty and income guidelines similar to the ones in this policy; or
 the patient/responsible party presents with Medicaid, and Medicaid does not
pay.
D. Charity Processing Based on Extenuating Circumstances, i.e., Potential Charity Write-off
Absent Full Documentation.
There may be extenuating circumstances where resource testing cannot be completed
because the patient/responsible party does not/cannot (i) complete the FAA, or (ii)
provide supporting documentation listed in A or B, above. In those circumstances, a
manager may waive the required documentation and extend a charity care write-off,
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consistent with this Policy. The following may be considered by the manager to be
extenuating circumstances:
i. Patients identified as an undocumented residents or homeless through:

 Medicaid Eligibility screening
 Registration process
 Discharge to a shelter
 Clinical or Case Management documentation
 Absence of a credit report
ii. Patients that expire - if it is determined through family contact and/or courthouse records
that an estate does not exist, it may be considered for a charity write-off (even if the
patient had a spouse) upon documentation and with the manager’s review and approval of
a policy exception.
iii. Medically Indigent – In addition to the above, if a patient/responsible party meets the
medically indigent status based upon state guidelines or requirements, a charity write-off
may be applied after the manager completes a resource testing process for the
patient/responsible party.
7) Pending Medicaid Effect on Charity Write-off:
The Pending Medicaid and Pending Charity processes should not be concurrent processes.
Determination of Pending Medicaid should be resolved prior to evaluating for potential
Pending Charity.
8) Health Insurance Marketplace for Qualified Health Plans:
Pending qualification in the Health Insurance Marketplace may take place concurrently with
the Pending Charity process. The QHP enrollment is not retroactive. Rather, the coverage
becomes effective for future dates of service. Therefore, it is necessary to continue with the
Pending Charity process for visits occurring prior to QHP effective dates.
9) Charity Processing based on Federal Poverty Guidelines:

A. Patients with individual or household incomes of between 0-200% of Federal Poverty
Guidelines:
Patients with more than a $1,500 patient liability that fall within 0-200% of the FPL will
have the entire patient balance processed as charity write-off. Upon request by a patient
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and, if there are extenuating circumstances, accounts with out-of-pocket responsibility

balances of less than $1,500 may be reviewed and a charity write-off applied.
B. Patients with individual or household incomes of between 201- 400% of Federal Poverty
Guidelines:
Patients with incomes between 201% and 400% of FPL will have their balances capped
at a percentage of their income according to the table below. This percentage will be
determined using the patient's FPL.
 201% - 300% - balances capped at 3% of annual household income

 301% - 400% - balances capped at 4% of annual household income
Upon request by a patient and, if there are extenuating circumstances, accounts with
out-of-pocket responsibility balances of less than $1,500 may be reviewed and a
charity write-off applied.
C. Patients Who Are Uninsured:
Notwithstanding 9)A. and B. above, patients who are uninsured and who provide the
supporting income verification documentation and otherwise meet the requirements of
this Policy, will have their patient balance capped at the lesser of the amount calculated
under 9)A. or 9)B. above, or the amount calculated pursuant to the uninsured discount
model.
Balances from multiple accounts for the same patient may be considered together to
determine out-of-pocket responsibility minimums and for calculating the cap.
The write-off will be applied to the entire outstanding patient balance.
10) Refunds on Charity Accounts:

The general expectation is that all patients pay for services rendered if they are not fully
covered by a third party. Therefore, any amount paid by the patient (even if the patient
subsequently meets the charity write-off guidelines for their balance due), will be retained.
Only amounts paid by the patient that exceed the amount that patient would have paid had
they received the uninsured discount, or that exceed their out of pocket responsibility per their
insurance, will be refunded. For those patients that do meet the charity write-off criteria and
have made a partial payment, the charity write-off will be posted on the remaining patient
balance.
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11) Patient Dispute Process:

In the event a patient wishes to file a dispute and appeal their eligibility for a Charity write-off
under this policy, the patient may seek review from the Vendor Collections Management
Director, Hospital Chief Financial Officer or an SSC Executive as defined in the Charity
Review Appeal Process policy (PARA.PP.VCM.020).
12) Compliance with State regulations:

Each SSC should evaluate whether this Policy complies with the applicable state law and
regulations regarding charity care, e.g., California, Florida. If this Policy does not comply
with state law and regulations, each SSC must clearly document exceptions to this policy in
either a State specific policy or an addendum to this Policy.
13) Liens:
Under no circumstances will liens be considered on properties less than $300,000 in value.
REFERENCE:
 PARA.FT.VCM.606 Federal Charity Guidelines
 PARA.FT.VCM.638 Financial Assistance Application
 PARA.MF.VCM.804 Collection Charity Letters
 PARA.PARS.PP.009 Medicare Bad Debt and Recovery Logs Policy
 PARA.PP.VCM.019 Utilizing the Artiva Charity Process
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Attachment B
Uninsured Discount Policy
Vendor Collections Management Uninsured Discount Policy for Patients
PAGE: 1 of 13 REPLACES POLICY DATED: 04/01/2016
APPROVED: 12/22/2014 RETIRED:
EFFECTIVE DATE: 09/15/2016 REFERENCE NUMBER: PARA.PP.VCM.015
SCOPE:
All Self-Pay patient accounts, excluding elective cosmetic procedures, facility designated self-pay
flat rate procedures and scheduled/discounted procedures for International patients will be given an
Uninsured Discount.
The following also qualify for the Uninsured Discount::

 Accounts where insurance benefits have been exhausted or terminated
 Medicare outpatient self-administered drugs
NOTE: If a Parallon Client chooses to participate in the uninsured discount process and the processes
are different a client specific policy should be developed using this policy as the guideline and
making changes as applicable. Use the reference number identifying the client as defined in the
Policy and Procedure Development policy PARA.PP.GEN.001. (Example: PARA.PP.VCM.015L for
LifePoint)
PURPOSE:
To define the process for selecting the appropriate Self-Pay IPLAN, providing patients with
information regarding available discounts and processing discounts for patients assigned one of the
Uninsured Discount IPLANS.
POLICY:
All Self-Pay patient accounts will receive an uninsured discount, with the exception of elective
cosmetic procedures; facility designated self-pay flat rate procedures, scheduled/discounted
procedures for International patients and accounts meeting the charity guidelines. Uninsured
discounts will also be applied to accounts where insurance benefits have been exhausted or
terminated. Medicare outpatient self-administered drugs will also receive the uninsured discount.
Accounts will be assigned one of the following Uninsured Discount IPLANS.
IPLAN IPLAN Description LOG ID IP Proc OP Proc

Code Code
099-40 Uninsured Discount Plan UINS 920970 920980
099-41 Uninsured Discount Plan – UINB 920971 920981
Burn Unit
099-42 Uninsured Discount Plan – UINT 920972 920982
Transplant
099-44 Uninsured State Specific (local) (local) (local)
099-45 Uninsured ESP – Left or Ref (local) (local) (local)
099-46 Uninsured ESP - Treated (local) (local) (local)
099-47 Uninsured Discount Plan – UINS 920970 920980
Patient Non-Compliance
099-49 Uninsured – Partially N/A (local) (local)

Exhausted Benefits
N/A Uninsured – Medicare Self- N/A N/A 957983
Administered Drugs
The discount amounts will be provided to each facility in a formal rate schedule document. The
patient will receive the Uninsured Discount unless the patient qualifies for a Charity Discount as
outlined in the existing Discount Charity Policy for Patients (PARA.PP.VCM.016).
Refer to Uninsured Discount FAQ for more information.
Patient Notification at the time of Registration:

If it is determined the patient is uninsured at the time of registration, the patient/responsible party will
be presented with an Uninsured Patient Information document (PARA.FT.VCM.015) that provides
information on the Uninsured Discount Policy and other available discounts and payment options.
This document will outline the process for uninsured discounts and inform the patient of additional
account resolution options (i.e. monthly payments). The patient/responsible party will be asked to
sign and date the document. The document will then be scanned into the imaging system and be
placed in the imaging Patient Folder document type, as a validation that information regarding
discounts has been communicated to all uninsured patients.
Patient Access Responsibilities at the Time of Registration:

Patient Access will be responsible for determining the appropriate IPLAN assignment from the table
above and for presenting the Uninsured Patient Information Document (PARA.FT.VCM.015) to the
patient/responsible party. Patient Access will explain the process as documented, answering
questions related to the document and obtaining a signature from the patient/responsible party
documenting that the information regarding available discounts was provided.
All requests for payment will be based on total estimated charges less the uninsured discount.
Patient Access will be responsible for requesting from the patient/responsible party the expected
patient liability amount by using a facility specific deposit schedule which has been updated to reflect
the Uninsured Discount.
Patient Access will be responsible for asking the patient/responsible party for payment in full or
monthly payment arrangements on the patient liability amount.
Inpatient and Outpatient self-pay patients who are able to make payment in full or monthly
payment arrangements.
 Assign the appropriate Uninsured Discount IPLAN.
 The Uninsured Discount IPLAN should reflect proration of 100% of the total charges for
the patient.
 A facility/SSC specific prompt pay discount may be applied in addition to the Uninsured
Discount as set forth in the PARA.PP.SS.035 Discount Policy for Patients.
Inpatient self-pay patients who are not able to make payment in full or monthly payment
arrangements and Outpatient self-pay patients will be considered for Medicaid eligibility.
 Assign the facility designated Pending Medicaid IPLAN as the primary payer.
o The Pending Medicaid IPLAN should reflect proration of 100% of the total
charges for the patient.
 Assign the Pending Charity IPLAN (099-50) as the secondary payer.
o Present the patient with a Financial Assistance Application for Charity
consideration. (Note: Patients who are elective will not qualify for Charity, so the
Pending Charity I-plan does not need to be added.)
 Assign the appropriate Uninsured Discount IPLAN as the tertiary payer.
Outpatient self-pay patients who are not able to make payment in full or monthly payment
arrangements and do not meet the Medicaid eligibility threshold.
 Assign the Pending Charity IPLAN (099-50) as the primary payer.
o The Pending Charity IPLAN should reflect proration of 100% of the total charges
for the patient.
o Present the patient with a Financial Assistance Application for Charity
consideration. (Note: Patients who are elective will not qualify for Charity, so the
Pending Charity I-plan does not need to be added.)
 Assign the appropriate Uninsured Discount IPLAN as the secondary payer.
All Inpatient and Outpatient self-pay patients registered for elective cosmetic procedures,
facility designated self-pay flat rate procedures and scheduled/discounted procedures for
International patients.
 Assign the facility/SSC designated IPLAN for the discounted/flat rate procedure.
Emergency Department self-pay patients who opt out to an ESP process will be assigned an
Uninsured ESP IPLAN.
 Assign the Uninsured ESP –Left or Referred IPLAN (099-45) as the primary payer if the
patient elects to Leave or be Referred during the ESP process.
 Assign the Uninsured ESP – Treated IPLAN (099-46) as the primary payer if the patient
receives treatment via the ESP process.
The default of Self-Pay IPLAN 000-00, due to the absence of an IPLAN, should be avoided once this
policy is implemented. All accounts that are not assigned an IPLAN and systematically assigned
Self-Pay 000-00 should be reviewed and moved to the appropriate IPLAN. All accounts excluding
Client/Industrial accounts must be registered with an appropriate IPLAN for the third party payer,
Medicaid Pending, Charity Pending, elective cosmetic/facility designated flat rate plan or an
Uninsured Discount Plan. A Business Objects script has been developed to assist in identifying
accounts without an IPLAN assignment.
Financial Counselor/Support Services/Collector/Early Out Agency Responsibilities:

If at any time it is determined that the patient is covered for these services by a health plan, the
Uninsured Discount IPLAN should be removed and the Uninsured Discount reversed. The Uninsured
Discount is limited to patients who have no third party payer source of payment. The IPLAN
assignment of the third party payer should be assigned to the account in place of the Uninsured
Discount IPLAN.
Retroactive consideration for Medicaid eligibility or Charity Discount:

Uninsured Discount Plan patients that retroactively are considered for Medicaid eligibility or Charity
discounts will have the appropriate Pending Medicaid eligibility and Pending Charity IPLANS
assigned as outlined in the Patient Access process above. The Uninsured Discount will be reversed
until determination of Medicaid eligibility and Charity can be ruled out.
Insurance Denials for Patient Non-Compliance:

Accounts where a denial is applied due to the patient’s lack of cooperation are considered
“uninsured”.
Based on the liability due from the payer, the following collection guidelines will be followed and
approval obtained prior to releasing liability to the patient where the patient failed to provide the
requested information timely. Once efforts to obtain required information is exhausted, the 09947
Uninsured Discount Iplan is assigned and remaining liability after the uninsured discount will
become the patient’s responsibility.
Artiva letters 1100 Request for Additional Information Request and 1153 Additional Insurance
Information Request are available to send to the patient for 1st and 2nd letter attempts. The letters
contain a dropdown to allow the requester to select the information required or enter free form text if
not listed in the dropdown. The next follow-up should occur based on the next follow-up cycle after
action is taken based on the standard liability stratification (top, high, etc.).
Once the appropriate collection activity and approval is completed, ensure both the Uninsured
IPLAN 099-47 and discount is applied appropriately. No approval is required for insurance liability
less than $1,500 ($2,000 ATL only); however; an audit must be performed monthly on 15 percent of
the accounts to ensure liabilities are released appropriately. To retain the original insurance plan
information, assign Uninsured IPLAN 099-47 as the primary payer and resequence the original
insurance IPLAN as the secondary payer.
 Assign the 099-47 Uninsured Discount IPLAN and resequence to the primary payer
retaining the original IPLAN as the secondary payer.
o The Uninsured Discount IPLAN should reflect proration of 100% of the total
charges.
Subsequently, if patient complies with the payer request, the uninsured IPLAN can be removed and
the original IPLAN information will move to primary intact.
Document actions and approvals with user name and ID in a clear and concise manner in the account
notes in Artiva.
Insurance Denials for Partially Exhausted Benefits:

Accounts where a denial is applied due to partially exhausted benefits, the Uninsured – Partially
Exhausted Benefits IPLAN (099-49) should be applied to the secondary position, after the payer with
partially exhausted benefits. A manual p-line must be performed to adjust the exhausted benefit
portion of the account by the facility Uninsured Discount percentage.
Guidelines to determine if an uninsured discount qualifies based on Partially Exhausted Benefits (All
three guidelines must be met):
 The remit indicates a Final Denial, or verbiage used on the remit such as “Exhausted
Benefits” or “Maximum Coverage Exceeded” and
 The patient was considered for Charity for the remaining balance and not approved and
 Days being considered for the uninsured discount were not covered by insurer. Also, no
insurance payment or contractual adjustment was received or posted for a portion of the
day’s charges.
Medicare Outpatient Accounts containing Self-administered Drugs:

Self-administered drugs (SADs) provided to Medicare outpatients are considered a non-covered

service by Medicare. SADs will not be tracked using an IPLAN. Charges for SADs will be uniformly
discounted 100% for all HCA facilities. Non-HCA will be discounted based on facility Uninsured
Discount percentage. A manual p-line using procedure code 957983 must be performed to adjust the
SAD portion of the account. Click here for more information.
Insurance Denials for no coverage including pre-existing:

Accounts where the insurance remits a denial of coverage including pre-existing conditions and there
are no other insurance coverage’s on file will be considered self-pay accounts. The IPLAN for the
insurance denial should be removed and the Pending Medicaid IPLAN added as primary (if the
account meets local screening guidelines), Pending Charity IPLAN assigned as secondary and the
Uninsured Discount IPLAN assigned as tertiary. A Financial Assistance Application will need to be
forwarded to the patient/responsible party.
Patient Statements:
Statements should not be sent out until the uninsured discount has been posted. Letters to a Self-Pay
patient/responsible party should not include the account balance until the Uninsured Discount has
been posted. If you use letters in your Medicaid Pending or Charity Pending process, you will need to
remove the account balance reflected on them.
Late Charges:
Accounts with the Uninsured Discount IPLAN as the primary payer should not have late charges
posted. If late credits are posted to the account, the Uninsured Discount should be recalculated to
reflect the correct patient liability. The Bill Code master file on Patient Accounting should be
modified to reflect no posting of late charges. Late charges after the Late Charge Days have elapsed
should be NPST (not posted) from the Late Charge Report.
State Specific requirements

Each SSC should evaluate whether this policy complies with the applicable State regulations
regarding Uninsured Discounts, and if it does not, clearly document exceptions to this policy in either
a State specific policy or an addendum to this policy.
HCA Trauma Facilities

After all efforts to identify funding for Uninsured patients have been exhausted, the trauma activation
charge will be discounted at 100% and then the standard uninsured discount will be applied to the
remainder of the account. The discount will be applied automatically when the uninsured iplan is
applied.
PROCEDURE:
Responsible Party Action
Self-Pay – Inpatient and Outpatient (able to pay)
Patient Access Determines the patient is not seeking services for elective cosmetic, a
flat rate procedure or is a scheduled/discounted International Patient.
Determines the patient can make payment or establish arrangements for

payment.
Assigns the Uninsured IPLAN as the primary payer.
Reviews and obtains a signature on the Uninsured Patient Information

Document from the patient or responsible party.
Calculates deposit from facility deposit schedule.
Collects deposit and documents account.
Self-Pay – Inpatient (unable to pay)

Determines the patient cannot make payment or establish arrangements

for payment.
Assigns the Medicaid Pending IPLAN as the primary payer.
Assigns the Charity Pending IPLAN as the secondary payer.
Assigns the Uninsured Discount IPLAN as the tertiary payer.

Presents the Financial Assistance Application to the patient or

responsible party.
Documents account.
Self-Pay – Inpatient and Outpatients for an Elective Cosmetic Procedure, Facility Flat Rate or
a scheduled/discounted International Patients
Patient Access Assigns the facility/SSC designated IPLAN for the elective cosmetic
procedure, facility flat rate procedure or scheduled/discounted
International Patient procedure.
Collects payment for elective cosmetic or facility flat rate procedure.
Documents account.
Self-Pay – Non Inpatient (unable to pay and for services that exceed the facility Medicaid
Eligibility threshold)
Determines the patient cannot make payment or arrangements for

payment.
Determines the charges will be over the Medicaid eligibility threshold.
Assigns the Medicaid Pending IPLAN as the primary payer.
Assigns the Charity Pending IPLAN as the secondary payer.
Assigns the Uninsured Discount IPLAN as the tertiary payer.


responsible party.
Documents account.
Self-Pay – Non Inpatient (unable to pay and charges for services that may not exceed Medicaid
eligibility threshold)
Determines the patient cannot make payment or arrangements for

payment.
Determines the complete charges for services cannot be made at time of

registration or
Determines the charges will not be over the Medicaid eligibility
threshold.
Assigns the Charity Pending IPLAN as the primary payer.
Assigns the Uninsured Discount IPLAN as the secondary payer.


responsible party.
Documents account.
Self-Pay – Emergency Department Registrations
Patient Access EMTALA guidelines must be adhered to for all ED patients.
Assign the Charity Pending IPLAN as the primary payer.
Assign the Uninsured Discount IPLAN as the secondary payer.
Documents account accordingly.
Self-Pay – Emergency Department Departures (able to pay)

Patient Access Determines the patient can make payment or arrangements for payment.
Removes the Charity Pending IPLAN (if assigned at time of

registration)
Assigns the Uninsured IPLAN as the primary payer. If the patient opts
out for the ESP process, assign the appropriate ESP IPLAN.

Calculates deposit from facility deposit schedule.

Collects deposit and documents account.

Self-Pay – Emergency Department Departures (unable to pay)
Patient Access Determines the patient cannot make payment or arrangements for
payment.
Ensures the Charity Pending IPLAN is the primary payer
Ensures the Uninsured IPLAN is the secondary payer.

Documents account.
Monitoring Inpatient and Outpatient Uninsured Discounts
Vendor Collections Reviews Self-Pay accounts with the Uninsured Discount Plan as the
Management primary payer for appropriate posted discount.
Notifies Payment Compliance of accounts with Uninsured Discount

Plan as the primary payer that are final billed and do not reflect an
Uninsured Discount.
Ensures that all Statements are held until the Uninsured Discount is
posted for patients who have the Uninsured Discount Plan as the
primary payer.
Ensures that all Letters to a Self-Pay patient/responsible party do not

include the account balance until the Uninsured Discount has been
posted
Self-Pay - Medicaid Eligibility Denied
Vendor Collections Determines the patient IS NOT eligible for Medicaid Coverage.
Management staff
Deletes the Medicaid Pending IPLAN and the system will automatically
move the Charity Discount IPLAN to the primary position and the
Uninsured Discount IPLAN to the secondary position.
Considers the patient for a Charity Discount based on

PARA.PP.VCM.016 Discount Charity Policy for Patients.
Self-Pay – Charity Discount Denied

Vendor Collections Determines the patient IS NOT eligible for a Charity Discount
Management staff
Deletes the Charity Pending IPLAN and the system will automatically
move the Uninsured Discount Plan to the primary position
Non-Concuity facilities processes an IZ transaction to ensure that the

Uninsured Discount IPLAN Log ID performs discount calculation
Insurance Denials – Patient Non-Compliance

Collections and/or Third Party payer denies coverage due to patient fails to comply with
Support Services request for information or payment of premium (QHP 8X addendum).
Sends the patient one or two letters and places one or two phone calls
depending on the liability due.
Obtains appropriate approval to release liability to the patient.
Assigns the Uninsured IPLAN – Patient Non-Compliance (099-47) as

the primary payer
Resequence the original IPLAN to secondary payer. The system will

post the uninsured discount. Keeping the original IPLAN on the account
retains the insurance information in the event the patient subsequently
complies with payer request.
Documents Account.
For accounts with liability due <$1000, perform an audit on a 15%

sample to confirm one letter was sent and time allowed for the patient to
respond before releasing liability to the patient.
Insurance Denials – No Coverage or Pre-existing
Collections and/or Third Party payer denies coverage due to no coverage or pre-existing.
Support Services
Remove Third Party IPLAN from account.

Add Pending Medicaid as primary payer and Charity Pending 099-50 as
secondary payer.
Send Financial Assistance Application to patient/RP
Insurance Denials – Partially Exhausted Benefits

Collections and/or Third Party Payer denies for partially exhausted benefits.
Support Services
Adds the Uninsured – Partially Exhausted Benefits IPLAN (099-49)
into the secondary position following the partially exhausted benefits
payer IPLAN.
Processes a manual p-line for the facility approved Uninsured Discount

on the portion of the account partially denied due to exhausted benefits
and re-prorates to patient liability.
Medicare - Self-
administered Drugs
MSC Process Will identify billed claims from the billing database that require a SADs
uninsured discount. Charges for SADs will be uniformly discounted
100% for all HCA facilities. Non-HCA will be discounted based on
facility Uninsured Discount percentage. A p-line using procedure code
957983 will be entered in eTran. The p-line follows the standard
approval process defined in eTran. Once the uninsured discount is
posted to the account; the accounts follow the normal MSC collection
process. Click here for more information.
NOTE: Encounters reaching a zero balance will be moved to zero

balance status and will not require an uninsured discount.
REFERENCE:
PARA.FT.VCM.015 Uninsured Patient Information Document
Facility Specific Uninsured Discount Plan Deposit Schedule
Facility Specific Cosmetic Procedure Plan Policy and Procedure
PARA.PP.SS.035 Discount Policy for Patient
PARA.PP.VCM.016 Discount Charity Policy for Patients

PARA.PP.GEN.001 Policy and Procedure Development
Self-Administered Drug Discount effective 04/01/2016
Self-Administered
Drugs 04012016.docx
QHP- denial code 8X addendum
QHP denial code 8X

specific to collection follow up 10.24.16.docx
Uninsured Discount FAQ 04/01/2016
Uninsured Discount
Plan FAQ 04012016.doc
Attachment C
Patient Liability Protection Policy
HCA

ASC Business Office ASD Patient Liability Protection Financial Assistance
Policy for Patients
PAGE: 1 REPLACES POLICIES DATED:
APPROVED: RETIRED:
EFFECTIVE DATE: 5/1/2019 REFERENCE NUMBER: ASD.BO.DISC.011
SCOPE:
Applies to all surgery centers operated by the Company’s Ambulatory Surgery Division. Facilities
located in joint-venture markets may need to follow the local joint venture’s policy.
PURPOSE:
To define the policy for providing partial financial relief to patients who receive medically necessary
care, have an outstanding balance exceeding $10,000 and meet the other conditions as outlined in the
policy. Adjustments to the patient liability are calculated using a scaled percentage to the income
levels (200-500%) established by annual Federal Poverty Guidelines.
POLICY:
The center may offer a Patient Liability Protection (PLP) Discount to the procedure charges only of
patients who meet the qualifications indicated in this policy. This policy does not apply to charges
for implantable items (including external components), drugs or high cost supplies. Adjustments for
those items are controlled by the provisions found in the ASD Uninsured Discount Policy,
ASD.BO.DISC.010.
For a PLP Discount write-off review to be considered, the following conditions will apply to patients
who:
a.) are considered to be uninsured or under-insured,
b.) have a household income that falls between 200% to 500% of Federal Poverty Guidelines
(FPG) levels,
c.) have received medically necessary care,
d.) do not qualify for state or federal assistance,
e.) incur a net patient liability of $10,000 or more on procedure service, and
f.) are unable to make full or partial payment on their patient liability because of income
limitations or inability to participate in an external financial arrangement.
Note that patients who have a net patient liability of at least $1,000 and who meet 0-200% of the
respective family size FPG levels will have a Charity Discount up to 100% of the net patient liability
as processed under the Charity Discount Policy for Patients ASD.BO.DISC.005.
The patient/guarantor should initiate the request for debt relief with center personnel based on his/her
specific situation in meeting the financial obligations of the services received.
The center’s Regional CFO or his/her designee (Regional BOD/BOM) must approve any potential
PLP Discount adjustment before the center may communicate the adjustment to the patient/guarantor.
HCA

Policy for Patients
APPROVED: RETIRED:
Similar to the Charity Discount Policy’s provisions and for purposes of this policy, only patients
receiving medically necessary care are considered for application of this policy, i.e., cosmetic surgery
procedures are disqualified. To be eligible the following classes of patients may qualify for a PLP
Discount:
1) Under-insured patients (i.e., those patients with some form of third party payer coverage for
health care services but such coverage is insufficient to pay the current bill) with an out of
pocket responsibility of at least $10,000, when the 200-500% FPG income thresholds are met,
or
2) Uninsured patients (i.e., those patients with no third party payer coverage for health care
services whatsoever), who have received the Uninsured Discount and who have advised the
business office staff they are unable to pay their account balance(s), when FPG thresholds are
met.
A validation must be completed to ensure that if any portion of the patient's medical services can be
paid by any federal, or state governmental health care program (e.g., Medicare, Medicaid, Champus,
Medicare secondary payor), private insurance company, or other private, non-governmental third-
party payor, that the payment has been received and posted to the account. No PLP Discount should
be applied to a case with any outstanding payer liability, i.e., all other potential payment sources must
be posted to the patient’s account before application of the PLP Discount adjustment.
All accounts (including Medicare patients) will be required to have supporting income verification
documentation. Medicare requires independent income and resource verification for a charity care
determination with respect to Medicare beneficiaries.
Income Verification:
All Medicare beneficiaries, in addition to a thoroughly completed Financial Assistance Application
(FAA), will be required to have supporting documentation for income verification. The preferred
income documentation will be the most recent year’s Federal tax return (Form 1040). A Medicare
beneficiary unable to provide his/her most recent Federal tax return may provide two pieces of
supporting documentation from the following list to meet this income verification requirement:
 State income tax return for the most current year
 Supporting W-2 and 1099 forms
 Most recent bank and broker statements (listed in the Federal tax return)
 Current credit report
HCA

Policy for Patients
APPROVED: RETIRED:
For non-Medicare patients, in addition to the FAA, at least one type of supporting income verification
documentation should be requested. However, a patient’s inability to provide the requested income
documentation will NOT affect his or her access to receiving the PLP Discount. The thorough
completion of the FAA will be the acceptable “minimum” for determining the discount. In addition
to the above-referenced documentation, the following may be used for non-Medicare patients as well:
 Most recent employer pay stubs
 Written documentation from income sources
 Copy of all bank statements for the last three months
After thorough review of the Financial Assistance Application, a manager may waive supporting
documentation on non-Medicare, non-Champus, non-Medicaid, and non-Medicare Secondary Payor
accounts only when it is apparent that the patient/responsible party is unable to meet the supporting
documentation requirement but clearly meets this discount’s guidelines.
Resource Verification: Medicare Accounts Only

Per policy LL.GEN.001 Waiver of Medicare Copays and Deductibles, in order to adjust off the
patient responsible portion, Medicare patients will need to undergo an individualized, good faith
assessment of financial need. Medicare patients will be required to provide the most current year’s
Federal tax return or the following supporting documentation to support resource testing:
 Supporting W-2
 Supporting 1099
 Most recent bank and broker statements listed in the recent Federal tax return
The financial assessment (to validate adjusting off the patient portion) is in lieu of continuing normal
collection efforts to secure payment of the amount. Under no circumstances will liens be considered
on primary residential property less than $300,000 in value.
All efforts should be documented in a clear, concise and consistent manner in the billing system. Staff
should demonstrate respect and integrity in all internal and external dealings. Confidentiality and
security of the patient’s information are considered of utmost importance and will be adhered to by all
staff.
Pending Medicaid Effect on PLP Discount

If the patient indicates that Medicaid is pending, the final status of that effort must be known before
evaluating the case for this discount. This may force a delay in applying the PLP Discount.
HCA

Policy for Patients
APPROVED: RETIRED:
PROCEDURE:
PLP Discount Processing based on Federal Poverty Guidelines
If a net patient liability exceeds $10,000 after all insurance payments and contractuals have been
considered, and the patient has requested debt relief (but does not qualify for the Charity Discount)
then the PLP Discount will be calculated using the following tables.
1. Establish if the patient’s household income qualifies within Table A’s 200% to 500% range of
FPG income levels for the respective family size.
2. Once determined, then locate the appropriate income column in Table B for the respective
family size to identify the appropriate adjustment percentage to be applied against the net
patient liability.
3. Calculate the amount by multiplying the percentage against the net patient liability.
4. Provide the Regional CFO or his/her designee with the supporting information and request
approval for processing the PLP Discount adjustment. If approval is granted, inform the
patient of the expected adjustment.
5. Post the calculated amount using the journal code PLPWO for entry on the patient’s account
once:
a. all final charges have been posted if the patient is self pay, OR
b. all payments have been posted if the patient had insurance coverage.
ASD PLP Financial Assistance Policy - Table A

FPG 2019 Income Income Income Income
Family Size Level 200% 300% 400% 500%
1 $12,490 $24,980 $37,470 $49,960 $62,450
2 $16,910 $33,820 $50,730 $67,640 $84,550
3 $21,330 $42,660 $63,990 $85,320 $106,650
4 $25,750 $51,500 $77,250 $103,000 $128,750
5 $30,170 $60,340 $90,510 $120,680 $150,850
6 $34,590 $69,180 $103,770 $138,360 $172,950
7 $39,101 $78,202 $117,303 $156,404 $195,505
8 or more $43,430 $86,860 $130,290 $173,720 $217,150
HCA

Policy for Patients
APPROVED: RETIRED:
ASD PLP Financial Assistance Policy - Table B

Income % of
FPG 201-300% 301-400% 401-500%
Family Size PLP Discount Adjustment %
1 50% 40% 30%
2 50% 40% 30%
3 50% 40% 30%
4 40% 30% 25%
5 40% 30% 25%
6 30% 25% 25%
7 30% 25% 20%
8 or more 25% 20% 20%
Example: Patient has a limited insurance plan leaving him with a deductible of $10,000. The
patient’s household family size is 4, with a verified income of $80,000. This puts him in the 301-
400% category and for his family size, a 30% PLP Discount of $3,000 (10,000 x 30%).
Refunds on accounts with a PLP Discount

The general expectation is that all patients pay for services rendered if they are not fully covered by a
third party. Therefore, any amount paid by the patient will be retained. Only amounts paid by the
patient that exceed the amount that the patient would have paid had they received the Uninsured
Discount, or that exceed their out of pocket responsibility per their insurance will be refunded.
REFERENCES:
U.S. Dept. of Health & Human Services Poverty Guidelines
PLP Financial Assistance Policy PARA.PP.VCM.030
ASD Charity Discount Policy for Patients ASD.BO.DISC.005
ASD Uninsured Discount Policy for Patients ASD.BO.DISC.010
Waiver of Medicare Copays and Deductibles LL.GEN.001
Attachment D
Mission Health Financial Assistance Discount Policy
MANUAL: POLICY NUMBER:
Leadership; Revenue Cycle 1LD.RC.0026
TITLE: PAGE NUMBER:
Financial Assistance Discount Policy 1 of 19
ORIGINATION DATE: REVIEW DATE: REVISION DATE:
October 1, 1991 N/A April 13, 2017
CONTENT MANAGER:
Jeff Hardin MHA – Executive Director, Collections and Financial Sponsorship
APPROVED BY:
Charles Ayscue – Senior Vice President, Finance and Chief Financial Officer
Board of Directors (October 27, 2015)
The above named individuals have reviewed this document and certified their approval of said document
via an electronic approval system considered equivalent to an actual signature on paper.
APPLIES TO:
This Financial Assistance Discount Policy of Mission Health System, Inc. is applicable to health
care services provided by the Mission Health facilities listed in Appendix C.
POLICY:
Within the constraints of prudently available resources, it is the policy of Mission Health System,
Inc. (“Mission Health”) to provide relief for medical expenses incurred by individuals and families
who do not have the financial resources to pay in whole for their health care services. Mission
Health will balance obligations to provide uncompensated care for patients who are unable to pay
with its fiduciary responsibility to preserve assets for serving future patients. Mission Health will
make reasonable efforts to screen patients who are uninsured in an effort to identify a source of
financial sponsorship. Cases may be reviewed during hospitalization, post discharge upon patient’s
request, or if Mission Health staff identifies an additional need.
This policy defines financial assistance discount parameters for individual patients. Mission
Health’s financial assistance discount capacity for a given fiscal period defines the parameters
within which management will seek to administer this policy. Financial assistance discounts are
determined using criteria such as income and household size. With these criteria, patients may be
eligible to receive a discount off their total responsibility of account balances based on their
annualized total income in relation to the most recently published Health and Human Services
(HHS) Federal Poverty Guidelines (FPG) (https://aspe.hhs.gov/poverty-guidelines).
This is a controlled document for internal use only. Any documents appearing in paper form are not
controlled and should be verified with the electronic file version prior to use.
1LD.RC.0026, Financial Assistance Discount Policy Page 2 of 19
Percentage of
Financial Assistance Discount Amount
HHS FPG
Inpatient, Observation, ER & Other
OP Surgery, OP Cath Outpatient Physician Services
Less than or
100%, $50 Visit Fee 100%, $25 Visit Fee 100%, $10 Visit Fee
equal to 100%
101% to 200% 100%, $500 Visit Fee 100%, $75 Visit Fee 100%, $20 Visit Fee
201% - 300% 70% 70% 70%
A. PURPOSE AND GUIDING PRINCIPLES
1. We serve the health care needs of all patients regardless of the patient’s ability to pay.
2. For non-emergency health care needs, even for patients who might qualify for discounts
under this policy, patients must work collaboratively with a Mission Health Representative
to establish appropriate payment arrangements. Financial counseling is provided to patients
who seek health care services including efforts to help such patients identify available
programs or financial assistance for which they might qualify.
3. Upon request, patients are provided detailed charge information in a meaningful format for
the charges they incurred for services.
4. Mission Health informs the public about the Financial Assistance Discount policy, the
policy application form, and the plain language summary of the policy by messaging on
patient billing statements, the Mission Health website, conspicuous postings throughout
each facility, patient friendly materials in public areas of the facilities, financial counseling
with patients and families, and upon request without charge. The plain language summary
of the policy is offered to patients as part of the admission process and displayed on the
back of the billing statements.
5. Patients can get additional information, including a list of hospitals and physician practices
covered under the Mission Health Financial Assistance Discount policy, as well as apply
for financial assistance by the following:
a. On-line at the Mission Health web site: http://www.mission-health.org/financial-
assistance.php
b. In person at the Mission Health Business office, 50 Schenck Parkway, Asheville, NC
28803
c. By phone at (828) 213-1500 or 1-800-848-8732
6. Mission Health staff will work in collaboration with the patient and appropriate community
health and human services agencies, and other organizations that assist people in need of
health care services to determine available funding sources.
7. All policies and procedures applying to financial assistance and financial clearance are
applied consistently and include reasonable efforts to ensure that financial assistance is
offered before any collection agency assignment.
8. Mission Health staff members who work closely with patients are educated and trained
about billing, financial assistance, and collection policies.
9. All patients are afforded an opportunity to establish reasonable payment plans.
10. Mission Health reserves the right to amend a final decision or reverse a financial assistance
discount previously recorded if it is needed to secure third party insurance coverage, if it
is determined that additional third party payer resources were or would have been available,
if the patient did not reasonably cooperate as required by this policy, if some information
provided may be false, or if the determination was made in error. Patients will be notified
and afforded an opportunity to provide clarification.
11. Mission Health reserves the right to require proof of income if there is reason to believe
the information provided is not complete and accurate.
12. Mission Health will comply with all rules and regulations related to financial assistance
policies. In particular, Mission Health will comply with 26 USC 501(r) as it relates to
requirements regarding financial assistance policies, emergency medical care policies,
limitation on charges and billing and collection requirements.
13. Mission Health limits amounts charged for medically necessary care provided to
individuals eligible for assistance under the Financial Assistance Discount Policy (FADP)
to not more than the amounts generally billed to individuals who have insurance covering
such care and prohibits the use of gross charges.
14. Mission Health will protect patient privacy and confidentiality throughout the process of
requesting and receiving Financial Assistance from Mission Health.
DEFINITIONS:
A. Amounts Generally Billed (AGB)– Mission will use the look-back method in determining
AGB for any medically necessary care it provides to a FADP-eligible individual. The AGB
percentage will be calculated annually by dividing the sum of all claims for medically
necessary care that have been paid in full during a prior 12-month period by the sum of the
associated gross charges for those claims. Claims paid will include claims paid by both
Medicare fee-for-service and all private health insurers as primary payers, together with any
associated portions of these claims paid by Medicare beneficiaries or insured individuals in the
form of Visit Fees, co-insurance or deductibles.
The AGB percentages for each hospital facility are listed below:
Facility AGB
Mission Hospital 39.90%
Angel Medical Center 37.97%
Blue Ridge Regional Hospital 38.77%
Highlands-Cashiers Hospital 58.10%
McDowell Hospital 35.29%
Transylvania Regional Hospital 41.94%
CarePartners 65.91%
Asheville Specialty Hospital 40.30%
B. Federal Poverty Guidelines – The standards used by the United States’ Department of Health
and Human Services (HHS) for determining whether a person or family is financially eligible
for assistance or services under a particular federal program. The Federal Poverty Guidelines
(FPG) is updated annually by HHS, and is published each year in the Federal Register. The
FPG in effect at the time of the Financial Assistance Application review and determination
will be used. Current information about the FPG can be found on the HHS web site at:
https://aspe.hhs.gov/poverty-guidelines.
C. Financial Assistance Application Period – The application time period patients may apply for
financial assistance discounts is 240 days from the first billing statement. Accounts beyond
this 240 day application period are not eligible for a financial assistance discount unless there
are special circumstances that warrant an exception and are approved by management.
D. Financial Assistance Discount Policy (FADP) - Eligible Account – An eligible account is an

account of a patient from a Mission Health facility listed in Appendix A where there is an
outstanding balance due from the guarantor, where the annualized total income (based on
Mission Health’s procedure for calculating income) is at or below 300% of the Federal Poverty
Guidelines for the patient’s family/household, and where medical necessary services were
provided. Any other discounts negotiated with patients, third party payers, employers,
attorneys, or others are not governed under this policy. Accounts for services listed in
Appendix A are not eligible for financial assistance.
E. Eligible Weight Management Services – Weight management services that are eligible for a
discount include office visits with a licensed or registered provider (MD, PA/FNP,
Psychologist, Behaviorist, and Dietician) at Mission’s Weight Management Center. Bariatric
surgery services are eligible for those patients who reside in Mission Health’s 18 county
service area in Western North Carolina (Appendix B) and have been approved by Mission’s
Weight Management Center. Bariatric surgery Financial Assistance discount criteria is as
follows:
• HHS FPG 0% to 200% - Eligible for a 100% discount with a $500 Visit Fee paid in
advance.
• HHS FPG 201% to 300% - Eligible for a 70% discount.
F. Income – Income is money received on a regular basis from employment or rendering services,
or through investments, government income benefits, or retirement benefits. Income is
evaluated by looking at the past 12 months of income for the patient. If patient is married,
income is evaluated by looking at the past 12 months income of the patient and the spouse. If
the patient is a child under the age of 18, income is evaluated by looking at the the past 12
months income of the parents or legal guardian(s). Common sources of income include money
received from: employment or services rendered, Social Security, retirement income, disability
benefits, survivor benefits, veteran’s benefits, child support, unemployment compensation, and
rental income.
G. Family/Household – The family/household is inclusive of those living in a home comprising a

single family. Dependents of the financially responsible party are also included regardless of
their residence. Examples of individuals which can be included as members of a
family/household include (but are not limited to):
1. Patient
2. Spouse
3. Partner sharing the home
4. Mother/Legal guardian of dependent child(ren) 17 years old and under
5. Father/Legal guardian of dependent child(ren) 17 years old and under
6. Dependent children 17 years old and under
7. Other adults living in the home
H. Financial Assistance – When Mission Health qualifies a patient for financial assistance based
on approved qualification criteria, it conditionally and gratuitously suspends its legal right to
demand full compensation for outstanding charges due from the patient. Full compensation
shall mean the amount of money that Mission Health is entitled to receive for a particular health
care service or product if no discounts are applied. An application is initiated by completion of
the Financial Statement. Any financial assistance discount for which a patient may be deemed
eligible is strictly provisional until it becomes final as provided in this policy. Until a
provisional discount becomes final, the patient’s legal obligation to render full compensation
continues. In addition, a discount determination that has become final may be reopened and
modified by Mission in the circumstances specified herein. This policy is not a contract, and
no financial assistance discount determination, whether provisional or final, neither constitutes
a contractual agreement nor creates any legal or equitable right or property interest for the
patient. No financial assistance discount administered pursuant to this policy involves a
transfer of any funds, federal or otherwise.
I. Uninsured Patient – A person who has no health insurance, or no health insurance coverage.
J. Insured Patient – A person who has a health insurance policy.
PROCEDURE FOR DISCOUNT DETERMINATION:
A. Emergency Services
1. Mission Health fully complies with all obligations imposed by the Emergency Medical
Treatment and Active Labor Act (“EMTALA”) and the 501(r)(4)(B)), Emergency Medical
Care Policy, and related regulations. This includes but is not limited to providing a medical
screening exam to any patient who comes to Mission Health emergency departments and
requests an examination or treatment for an emergency medical condition, including active
labor without regard to a patient’s ability to pay and without requiring any pre-treatment
financial screening. This practice also relates to the provision of either stabilizing treatment
or transferring patients with emergency medical conditions. Additionally, Mission Health
will not engage in actions that discourage patients from seeking emergency medical care
nor will any activities be undertaken that interfere with the provision of emergency medical
care. Prohibited actions include demanding emergency department patients to pay before
receiving treatment or permitting debt collection activities to occur in the emergency
department and in other locations where emergency medical care is provided.
B. Discount Determination Procedures
1. Mission Health may automate some financial assistance determinations. Patients may
appeal an automated decision for manual review. There are certain situations that qualify
an account for a 100% presumptive or indigent discount and do not require an application
or supporting financial documentation. Account notes and medical records may support
eligibility determination for Medicaid eligible patients with residual balances, patients
living in government assisted housing, homeless patients, incarcerated patients, patients in
substance abuse treatment programs, deceased patients without an estate, or patients in
situations that make it impractical to apply for financial assistance. In addition, 100%
presumptive discounts may be automatically applied to accounts where the patient’s
financial assistance expiration date is within 12 months of the date of service.
2. Any patient who has or anticipates incurring financial obligations to Mission Health for
FADP eligible services, may at any time (preadmission, during the course of a treatment,
or at any time after treatment) request a determination for qualification for financial
assistance. This policy applies to both patients with and without insurance benefits.
3. A patient’s insurance status (Uninsured or Insured) will be based on whether the patient
has insurance coverage on the date of service and will be evaluated at the account level.
4. All insured patients with a denied claim on a FAP-Eligible Account, which leaves them
responsible for the charges, are eligible to apply for a financial assistance discount.
5. For financial assistance eligibility, the assessment of the annualized total income of those
legally liable for health care services will be required. This may include those who have
signed a Potential Health Plan Denial (PHPD), those who have signed an Advance
Beneficiary Notice (ABN), the patient, the financially responsible party, or a spouse if
living in the household or legally responsible for the health care debt.
6. Upon evaluation of the patient’s annualized total income and satisfaction of any other
eligibility criteria contemplated herein, financial assistance discounts will be provisionally
applied according to the chart in policy section I, contained herein. A Self-Employed
patient’s annualized income will be calculated based on the total income reflected on their
most recent tax return. Patients with a total income greater than 300% of the most recently
published HHS Federal Poverty Guidelines may be eligible for a discount under the
catastrophic provision of this policy.
7. Verification of income may be done in a variety of ways. Some of the most common
include, but are not limited to, pay stubs, tax records including W2’s and tax returns, and
bank statements. If a patient does not have income or does not have any documentation of
their income, they will be asked to complete and sign a Statement of Daily Living Expenses
as documentation of their situation and how they are able to meet daily living needs.
8. Other situations qualify for a 100% indigent care discount and do not require an application
or supporting financial documentation. In these situations, qualified hospital staff will
reasonably determine indigent status using due diligence, documenting their findings based
on available information in the account notes, medical records and external sources.
9. To complete the discount determination process for any discount described in this policy,
an applicant must reasonably cooperate with Mission Health staff and other potential
payers to exhaust the possibility of qualifying for governmental or other third party
payment for medical services requested or received. Exhaustion of such possibilities
includes fulfilling a deductible waiting period, which means postponing the finalization of
any provisional financial assistance discount for which a patient might be eligible until
such time as it is reasonably determined by Mission that the medical bill at issue cannot be
used to reduce or satisfy the patient’s deductible or spend-down for purposes of
governmental or third-party insurance.
10. An essential element of the financial assistance process involves provision by the patient
of complete information and verification as needed about all relevant income information
for the patient and anyone else financially obligated for payment of the medical services
requested or provided. This information includes but is not limited to completion of the
Patient Financial Statement and provision of any related verifications requested.
Additionally, if the balances are $2,000 or less, the patient is not required to sign the Patient
Financial Statement or provide income verifications.
11. Patients who are eligible for provisional discounts will be notified in writing at the time of
approval as to the level of the provisional discount, any applicable Visit Fees, and the
approval period.
12. All provisional discounts as reductions in the patient’s financial obligation to Mission
Health will become final and will be credited to the patient’s account only following a final
determination by Mission that the patient has complied with this policy including the
requirements of cooperation, exhaustion, and deductible waiting periods. A record of all
discounts that become final and are written off pursuant to this policy will be maintained.
13. Patients receiving a full discount may be assessed a Visit Fee for each visit. However,
patients will not be denied services due to an inability to pay. The Visit Fee is not a
threshold for receiving care and thus, is not a minimum fee or co-payment. The Visit Fees
for insured patients are subject to the lesser of the applicable Visit Fee and the otherwise
applicable patient cost-sharing obligation (e.g. required co-pay under patient’s third-party
payor policy), subject to the contractual terms of the third-party payor.
14. Financial assistance discounts for uninsured accounts will be applied to the gross charges
for the account. Financial assistance discounts for insured accounts will be applied to the
patient’s responsibility after the insurance benefits have been applied to the account.
15. Once the provisional discounts have been applied, any remaining balance including Visit
Fees will be the patient’s responsibility and collected through the normal patient billing
and collection procedures and if unpaid, may be placed with a third party collection agency.
The actions which may be taken in the event of nonpayment for outstanding balances is
described in a separate billing and collections policy, a copy of which may be obtained at
no cost by contacting the Mission Health Business Office, 50 Schenck Parkway, Asheville,
NC 28803, (828) 213-1500 or 1-800-848-8732.
16. At the time of approval, provisional discounts will be applied to all existing account
balances meeting the eligibility criteria described in the policy. Financial Assistance Visit
Fees will not be applied to existing balances being discounted at the time of approval, but
will be due at the time of service for all future services during the patient’s approval period.
A patient’s inability to pay the Visit Fees at the time of service will not result in the patient
being denied services. Visit Fees not paid at the time of service will remain the patient’s
responsibility and will be collected through the normal patient billing and collection
procedures and, if unpaid, may be placed with a third party collection agency.
17. Patients approved for a provisional discount pursuant to Mission Health Financial
Assistance Discount Policy will need to be re-evaluated for financial assistance when they
require future services after 6 months from last discount approval date. If the patient is
receiving a Social Security monthly check, the financial assistance approval will be valid
for one year versus a 6 month period. All balances will be subject to the approved discount
percentage with the exception of accounts beyond the 240 day application period and those
accounts where the patient is deceased with an outstanding estate. A guarantor may re-
apply within the application period for financial assistance when total income or household
family unit change in a manner that warrants re-evaluation.
C. Catastrophic Discounts
Separate from the Financial Assistance discounts described in this policy, patient balances may
also be eligible for a Catastrophic Discount. In order to qualify, a completed Patient Financial
Statement must be signed by the guarantor, and all income must be verified. Upon meeting
these requirements, the patient’s balance due will be provisionally discounted such that after
other discounts in this policy become final and have been applied, the remaining balance will
not exceed 15% of the annualized total income, as documented on the signed financial
statement.
D. Control Mechanisms
1. Any person with authorized approval to sign off on provisional or final financial assistance
discounts will be prohibited from taking applications and/or making recommendations for
financial assistance write offs on their family members and friends. These applications
must be referred to another staff member for determination and completion. If any
relationships/situations are questionable, they should be forwarded to another authorized
person for completion. Violations will warrant disciplinary action.
2. Once a financial statement is completed and signed and a determination is made regarding
qualification for a provisional financial assistance discount, proof of income will be
required when the total amount of the balances at the time of determination are greater than
$2,000. Additionally, if the total amount of the balances at the time of determination are
$2,000 or less, the patient is not required to sign the financial statement or provide income
verifications. In cases where the determination is made on balances less than $2,000,
additional verifications will not be required during the approval period even if new
balances exceed $2,000.
3. A Revenue Cycle management team member will conduct quarterly departmental audits
of five random financial assistance applications. Results will be shared with a designated
Director of the Revenue Cycle followed by remedial education as appropriate.
4. Approval levels for Mission Health are:
$1 - $10,000 Designated Revenue Cycle Staff Members
$10,001 - $50,000 Designated Revenue Cycle Supervisor or Manager
$50,001 - $100,000 Designated Revenue Cycle Director or Executive Director
Over $100,000 Revenue Cycle Vice President
5. Mission Health Financial Assistance Discount Policy will be reviewed at least annually by
the Vice President of Revenue Cycle Management and recommendations for revisions,
updates and/or confirmation of no changes to the policy will be made and forwarded to the
Sr. Vice President of Finance and CFO for review and approval/signature.
Effective: 12/1/07
Reviewed: 10/91, 1/05, 10/06, 9/07, 8/09, 11/10, 4/11, 6/11, 11/11, 9/10/12, 10/31/12, 2/18/13, 8/15/13,
12/16/13, 7/01/14, 11/10/14, 10/01/16, 3/27/17, 4/13/2017
Appendix A
Accounts for elective and not medically necessary services are not eligible for financial
assistance discounts. Some examples of these services include, but are not limited to:
• Cosmetic procedures and surgery

• Food Products
• Supplements
Other services that are not eligible for financial assistance discounts include:
• Prosthetics and Orthotics

• Adult Day Care
• Private Duty Nursing
• Hospice Transitional Care
• Driving Evaluations
• Outpatient rehab services beyond the Medicaid treatment guidelines for patients with
Medicaid and uninsured patients.
• Weight Management Center Program Fees
Appendix B
Bariatric surgery services are eligible for Financial Assistance discounts if the patient meets the
criteria described in the policy and resides in Mission Health’s 18 county service area in Western
North Carolina listed below:
Avery
Buncombe
Burke
Cherokee
Clay
Graham
Haywood
Henderson
Jackson
Madison
Macon
McDowell
Mitchell
Polk
Rutherford
Swain
Transylvania
Yancey
Appendix C
The Mission Health Financial Assistance Discount Policy is applicable to health care
services provided by the following Mission Health facilities:
Hospitals:
Mission Hospital
McDowell Hospital
Transylvania Regional Hospital
Blue Ridge Regional Hospital
Angel Medical Center
Highlands Cashiers Hospital
CarePartners
Asheville Specialty Hospital
Physician Practices:
Advanced Cardiac Care Clinic

Advanced Cardiac Care Clinic - South
Angel Home Health and Hospice
Angel Medical Center - Anesthesia Services
Angel Medical Center - Emergency Services
Angel Medical Center - Hospitalists
Angel Orthopaedic Associates
Angel Pediatrics
Angel Primary Care
Angel Surgical Associates
Angel Surgical Associates - Highlands
Angel Urgent Care Center
Asheville Cardiology Associates
Asheville Cardiology Associates - Brevard
Asheville Cardiology Associates - Franklin
Asheville Cardiology Associates - Hendersonville
Asheville Cardiology Associates - Highlands
Asheville Cardiology Associates - Rutherfordton
Asheville Cardiology Associates - Sylva
Asheville Family Medicine
Asheville Hospitalist Group
Asheville Orthopedics Associates - Marion
Asheville Orthopedics Associates & Mission
Asheville Orthopedics Associates & Mission - Biltmore Park
Asheville Pulmonary & Critical Care Associates
Blue Ridge Medical Center - General Surgery
Blue Ridge Medical Center - Yancey Campus
Blue Ridge Regional Hospital - Hospitalist Dept
Brevard Cancer and Infusion Center
Brevard Family Practice
Brevard Internal Medicine and Pulmonology
Brevard Orthopaedics P.A.

Cancer Care of Western North Carolina
CarePartners Hospice & Palliative Care
CarePartners Outpatient Medical Clinic
CarePartners PACE
CarePartners Rehabilitation Hospital
Carolina Spine and Neurosurgery Center
Carolina Spine and Neurosurgery Center - Arden
Carolina Vascular
Carolina Vascular and Mission
Cashiers Medical Center
Community Medicine Old Fort
Family Medicine - Glenwood
Family Medicine - Nebo
Fullerton Genetics Center
Highlands-Cashiers Hospital - Anesthesia Dept
Highlands-Cashiers Hospital - Eckerd Living Center
Highlands-Cashiers Hospital - Emergency Department
Hope Women's Cancer Centers
Jane Woodruff Clinic
Low Vision Center
McDowell Hospitalist Group
McDowell Internal Medicine
McDowell OB/GYN McDowell Internal Medicine
McDowell Pediatric Associates
McDowell Surgical Services
McDowell Urgent Care
McDowell Urology
McDowell Women's Care
Medical Associates of Transylvania Regional Hospital
Mission Cancer Care
Mission Children's - Bryson City
Mission Children's - Sylva
Mission Children's Dental Program
Mission Children's Specialists
Mission Children's Specialists - 5 Vanderbilt satellite
Mission Children's Specialists - Child Safety
Mission Children's Specialists - Endocrinology
Mission Children's Specialists - Hospitalists
Mission Children's Specialists - Intensivists
Mission Children's Specialists - Neonatology
Mission Children's Specialists - Neurology
Mission Children's Specialists - Orthopaedics
Mission Children's Specialists - Pediatric Palliative Care
Mission Children's Specialists - Pulmonology
Mission Children's Specialists - Surgery
Mission Community Anesthesiology Specialists
Mission Community Obstetrics and Gynecology
Mission Community Orthopedics and Sports Medicine
Mission Community Primary Care - Grassy Creek
Mission Community Primary Care - Haywood

Mission Community Primary Care - Highlands
Mission Community Primary Care - Spruce Pine
Mission Community Primary Care-Cashiers (RHC)
Mission Community Primary Care-Highlands (RHC)
Mission Diabetes Project (Hospitalists)
Mission Family Practice
Mission Infectious Disease Associates
Mission Internal Medicine
Mission My Care Plus - Biltmore Park
Mission My Care Plus - Candler
Mission My Care Plus - Leicester
Mission Neurology - Inpatient
Mission Neurology - Outpatient
Mission Neurosurgery
Mission Orthopedic Trauma Services
Mission Pain Management - Angel Medical Center
Mission Pain Management - McDowell
Mission Pain Management - Spruce Pine
Mission Pain Management - Transylvania
Mission Palliative Care
Mission Pediatric Hematology/Oncology
Mission Primary Care - Burke
Mission Trauma Services
Mission Urology - Burke
Mission Weight Management Center
Mission Women's Care Bryson City
Mission Women's Care Franklin
Mission Women's Care Sylva
Mission WorkWell
Mission WorkWell - Marion
Mission WorkWell - Spruce Pine
MMA Psychiatric Services
Mountain Radiation Oncology and Mission
Olson Huff Center
Pisgah Surgical Associates
Pisgah Urology
Regional Surgical Specialists
Tallulah Health Center
Toxaway Health Center
Transylvania Home Care and Hospice
Transylvania Regional Hospital - CRNA Association
Transylvania Regional Hospital - ER Dept
Transylvania Regional Hospital - Hospitalist Dept
Transylvania Women's Care
Victoria Urological Associates
Vista Family Health
Western Carolina Women's Specialty Center
William M. Huffstutter, MD, PA
Wound Healing and Hyperbaric Center
The Mission Health Financial Assistance Discount Policy does not apply to services
provided by the following:
21st Century Oncology
ABC Pediatrics of Asheville
ABC Podiatry Center
ABCCM Medical Ministry
Advanced Dermatology & Skin Surgery
Adventist Health System
Albert B. Anderson, MD, PA
All Kids Pediatrics
AllCare Clinical Associates, PA
Allergy Partners of Western North Carolina
Alta Ridge Foot Specialists
American College of Obstetricians & Gynecologists
Andrew Lewis Rogers MD
Appalachian Eye Associates
Appalachian Foot & Ankle Associates
Arden Family Health Center
Art of Internal Medicine and Pediatrics
Asheville Aesthetic Plastic Surgery
Asheville Arthritis and Osteoporosis Center
Asheville Children's Medical Center
Asheville Dermatology Center
Asheville Endocrinology Consultants
Asheville Eye Associates
Asheville Family and Sports Medicine
Asheville Family Health Center
Asheville Gastroenterology Associates
Asheville Gynecology and Wellness
Asheville Head, Neck & Ear Surgeons
Asheville Heart
Asheville Hematology and Oncology
Asheville Hematology and Oncology - Marion
Asheville Internal Medicine
Asheville Medicine and Pediatrics
Asheville Neurology Specialists, PA
Asheville Obstetrics & Gynecology
Asheville Pediatric Associates
Asheville Pediatric Dentistry
Asheville Podiatry Associates
Asheville Psychiatry at the Grove Clinic
Asheville Radiology Associates
Asheville Urological Associates
Asheville Women's Medical Center
Autumn Care
Bakersville Community Medical Clinic
Biltmore Dermatology Associates
Biltmore Family Medicine

Biltmore Medical Associates
Biltmore OB/GYN Associates
Biltmore Plastic Surgery
Black Mountain Neuro-Medical Treatment Center
Blue Mountain Surgery
Blue Ridge Bone & Joint Clinic
Blue Ridge Bone & Joint Clinic - South
Blue Ridge Bone and Joint Clinic
Blue Ridge Cardiology
Blue Ridge Community Health Services
Blue Ridge Ear, Nose, and Throat, Inc.
Blue Ridge Family Practice & Sports Medicine
Blue Ridge Pediatric Dentistry
Blue Ridge Podiatry Associates
Blue Ridge Premier Medicine
Blue Sky Pediatrics Asheville
Brevard Health Center
Brian T. MacDowell, MD
Brosnan Eye Associates
Burrell Family and OB Care
Cannon Family Health
Cardiology Associates of the Carolinas
Carolina Hand and Sports Medicine
Carolina Internal Medicine Associates
Carolina Mountain Dermatology
Carolina Mountain Emergency Medicine
Carolina Mountain Gastroenterology
Carolina Mountain Psychiatry
Carolina Ophthalmology
Celo Health Center
Center for Family Guidance, LPC
Center for Plastic Surgery
Charles A. Shaller MD PLLC
Charles D. Lefler, MD PA
Charles George VA Medical Center - Compensation and Pension
Charles George VA Medical Center - Medical Service
Charles George VA Medical Center - Primary Care
Charles J. DePaolo, MD, PA
Chinese Acupuncture Clinic
Clayton Pediatric Dentistry
Community Family Practice
Comp Health Locum Tenens
Comprehensive Pain Consultants of the Carolinas
Crescent Anesthesia Associates
D&Y Locum Tenens
Dale Nash, MD Private Practice
Daniel M. Raiford, DDS, PA

David C. Matthews MD PA
Delta Locums
Dennis R. Campbell, DDS, PA
Dermatology of North Asheville
Dula Springs Wellness Center, PA
East Asheville Family Health Care
EmCare Physician Services
Extension Care Physicians
F J Ragaz, MD
Family Care of Fairview
Family To Family
Forest Dermatology
Foundation in Spine Health
Four Seasons Hospice & Palliative Care
Frances Warde Family Health
Franklin Family Practice
French Broad Pediatric Associates, PLLC
Fusion Healthcare Staff
Gainesville Eye Associates
Grace OB/GYN, PA
Great Beginnings
Gregory J. Dray, MD, PA
Hart Family Practice
Hayes Locums
Haywood Pathology Associates
Hendersonville Pediatric Dentistry
Hendersonville Pediatrics, PA - Brevard
Hendersonville Pediatrics, PA - Hendersonville
Hensley & Associates
Highlands Dermatology
HMP of Buncombe County, PLLC
Hominy Valley Family Health Center
Hospice and Palliative Care Center of Mitchell County
Hospice of McDowell County
Hot Springs Health Program
HP Partners
IPC Healthcare
J. Paul Martin, MD
J. Scott Baker, MD - Family and Community Care
James B. Payton, MD, PA
James C. Elliott, DDS, PA
JFK Alcohol & Drug Treatment Center
Joshua D. Paynich, DDS, PA
Kani L. Nicolls, DDS, PA
Kevin J. Foley, M.D., PA
KidzCare Pediatrics
Laborde Eye Group

Laurel OB/GYN
Lifepath Palliative Care
Locum Tenens
LocumTenens.com
Locumtenens.com LLC
Looking Glass Eye Center
Macon Cancer Center
Macon County Public Health
MAHEC Dental Health Center
MAHEC Family Health at Newbridge
MAHEC Family Health Center at Cane Creek
MAHEC Family Health Center Biltmore
MAHEC OB/GYN Specialists
Marianne C. Soufas, MD
Mars Hill Medical Center
Matthew K. Howard MD LLC
McCreary Cancer Center
McGee Dermatology Clinic
medAge
Medical Doctor Associates
Medical Heights OB-GYN, PA
Melissa Thingvoll MD PLLC
MemoryCare
Moore Foot & Ankle Specialists, PA
Morganton Eye Physicians, PA
Mountain Area Family Health Center
Mountain Area Pathology, PA
Mountain Area Pediatric Associates
Mountain Care Urology PLLC
Mountain Diabetes & Endocrine Center
Mountain Docs Family Medicine
Mountain Ear, Nose and Throat
Mountain Ear, Nose and Throat - Franklin
Mountain GI Associates
Mountain Integrative Medicine
Mountain Kidney & Hypertension Associates, PA
Mountain Medical and Surgical Group
Mountain Medical Arts, PLLC
Mountain Medical Associates
Mountain Podiatry, PA
Mountain Regional Arthritis Center
Nantahala Counseling Center
New Dawn Midwifery, Inc
New Horizons Women's Cancer Center
North Buncombe Family Medicine
October Road, Inc.
Office of Dr. Smoker and Dr. Folkner

Our Family Doctor
Pardee Urological Associates
Park Ridge Health Family Medicine
Park Ridge Pediatrics
Parkway Medical Group
Phoenix Physicians
Piedmont Reproductive Endocrinology Group
Pineiro Family Practice
Pisgah Family Health
Plastic Surgery Center
Plastic Surgery of Asheville
Richard T. Parmley, MD
Rockcliff Place Maxillofacial & Oral Surgeons
Sean Skierczynski, OD
Sentient Medical Systems
Sisters of Mercy Urgent Care Centers
Smoky Mountain Foot Clinic
Southeastern Sports Medicine and Podiatry
Staff Care
Steven Dean Stacy, DDS
Steven L. Cahan, MD, PA
Stewart J. Harley, MD
Stress Assessment Center
Susan B. Wise, OD PA
Taylor F. Townsend, DDS, PLLC
The Pisgah Institute
TIVA Healthcare
Trillium Family Medicine, PLLC
Twardon Family Care
Vein Clinic of North Carolina
Vickery Family Medicine
VISTA Staffing Solutions
Wayah Internal Medicine
Weatherby Locum Tenens
Western Carolina Digestive Consultants
Western Carolina Retinal Associates
Western North Carolina Community Health Services
Wiley S. Cozart III, DDS
William J. Claiborne, DDS, PA
WNC Dermatological Associates
WNC Ear, Nose, Throat, Head & Neck Surgeons
WNC Hypertension & Wellness Center
WNC Ray of Hope
Woodridge Psychological Associates
Woolfson Eye Institute
Attachment E
Description of HCA's Financial Assistance Policies
Mission Health Financial Assistance
The Mission Health Board of Directors concluded that, while some patients (particularly those seeking non-
emergent, elective services) would receive more financial assistance under the prior Mission Health policy,
overall HCA’s policies provide a greater aggregate amount of financial assistance to Mission Health’s patients.
The below policies reduce medical bills for patients:
Charity Discount:
 Assists patients making up to 400% of Federal Poverty Level (FPL).

 Primarily relates to emergent services; however, patients not qualifying for a charity discount would
likely receive an uninsured discount.
 A Financial Assistance Application and supporting documentation may be required to qualify for
charity discount.
 Qualifying patients are eligible for charity after pursuit of all third party payer sources has been
exhausted (e.g., Medicaid).
 Patients with income < 200% of FPL: full write off of liability
 Patients with income 201% – 300% of FPL: Patient responsibility capped at 3% of annual household
income.
 Patients with income 301% to 400% FPL: Patient responsibility capped at 4% of annual household
income.
 The charity policy for physician clinic visits is similar to the hospital policy.
Uninsured Discount:
 Assists most uninsured patients who do not qualify for charity and have no other payer source (for
example, do not qualify for Medicaid).
 Applies to both emergent and non-emergent procedures; however, special self-pay procedures (for
example cosmetic procedures) are excluded.
 The amount of the discount offered may vary by location or service (i.e., hospital vs. clinic).
 Discount is automatically applied (no application necessary)
Patient Liability Protection:
 Assists uninsured and underinsured patients with large balances compared to income.
 Applies to non-elective, emergent services and caps patient liabilities as a percent of income.
 A Financial Assistance Application and supporting documentation may be required to qualify for
discount.
Key Contact Numbers:

Patient Liaison: 828-651-6496
Pre-service:
Bill in Process: Refer to Patient Statement
Physician Contact, Dr. Hathaway:
Internal Email for Escalations: @HCAHealthcare.com
CONFIDENTIAL – Contains proprietary information. Not intended for external distribution.

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Attachment A

Charity Care Policy

6) Supporting Income Verification Documentation & Review:

 Most Recent Employer Pay Stubs

ii. Supporting income verification documentation through an electronic validation of

i. Patients identified as an undocumented residents or homeless through:

9) Charity Processing based on Federal Poverty Guidelines:

and, if there are extenuating circumstances, accounts with out-of-pocket responsibility

 201% - 300% - balances capped at 3% of annual household income

10) Refunds on Charity Accounts:

11) Patient Dispute Process:

12) Compliance with State regulations:

 PARA.FT.VCM.606 Federal Charity Guidelines

 PARA.FT.VCM.638 Financial Assistance Application

 PARA.MF.VCM.804 Collection Charity Letters

 PARA.PARS.PP.009 Medicare Bad Debt and Recovery Logs Policy

 PARA.PP.VCM.019 Utilizing the Artiva Charity Process

The following also qualify for the Uninsured Discount::

IPLAN IPLAN Description LOG ID IP Proc OP Proc

099-49 Uninsured – Partially N/A (local) (local)

Refer to Uninsured Discount FAQ for more information.

Patient Notification at the time of Registration:

Patient Access Responsibilities at the Time of Registration:

Financial Counselor/Support Services/Collector/Early Out Agency Responsibilities:

Retroactive consideration for Medicaid eligibility or Charity Discount:

Insurance Denials for Patient Non-Compliance:

Insurance Denials for Partially Exhausted Benefits:

Medicare Outpatient Accounts containing Self-administered Drugs:

Self-administered drugs (SADs) provided to Medicare outpatients are considered a non-covered

Insurance Denials for no coverage including pre-existing:

State Specific requirements

HCA Trauma Facilities

Self-Pay – Inpatient and Outpatient (able to pay)

Determines the patient can make payment or establish arrangements for

Assigns the Uninsured IPLAN as the primary payer.

Reviews and obtains a signature on the Uninsured Patient Information

Calculates deposit from facility deposit schedule.

Collects deposit and documents account.

Self-Pay – Inpatient (unable to pay)

Determines the patient cannot make payment or establish arrangements

Assigns the Medicaid Pending IPLAN as the primary payer.

Assigns the Charity Pending IPLAN as the secondary payer.

Assigns the Uninsured Discount IPLAN as the tertiary payer.

Reviews and obtains a signature on the Uninsured Patient Information

Presents the Financial Assistance Application to the patient or

Determines the patient cannot make payment or arrangements for

Determines the charges will be over the Medicaid eligibility threshold.

Assigns the Medicaid Pending IPLAN as the primary payer.

Assigns the Charity Pending IPLAN as the secondary payer.

Assigns the Uninsured Discount IPLAN as the tertiary payer.

Reviews and obtains a signature on the Uninsured Patient Information

Presents the Financial Assistance Application to the patient or

Determines the patient cannot make payment or arrangements for

Determines the complete charges for services cannot be made at time of

Assigns the Charity Pending IPLAN as the primary payer.

Assigns the Uninsured Discount IPLAN as the secondary payer.

Reviews and obtains a signature on the Uninsured Patient Information

Presents the Financial Assistance Application to the patient or

Self-Pay – Emergency Department Registrations

Patient Access EMTALA guidelines must be adhered to for all ED patients.