US healthcare · Front-end revenue cycle

Patient Access and Financial Clearance

Every claim is built on what the front desk captured. Patient access is the set of steps that happen before and at the point of care: scheduling the order, identifying the patient, recording the coverage, asking the Medicare questions, delivering the notices the law requires, estimating the bill, collecting what is due, and finding a payer for people who have none. This tutorial walks through each step, the 2026 rules that shape it, and the denials that start at registration.

BeforePre-service

Is this patient financially cleared?

Right person, active coverage, correct order of payers, authorization, estimate, notices.

Clearance happens days before the visit, not at the counter. Anything left to the day of service is a risk.

DuringArrival

Did we confirm, sign and collect?

Two identifiers, card and ID, MSP questions, consents, ABN where needed, point-of-service payment.

Thirty seconds of confirmation at check-in prevents weeks of rework after the claim.

AfterQuality

What did the denials tell us?

Registration accuracy audits, denial root causes, feedback to the people who keyed the data.

A registration error costs seconds to fix at the desk and weeks to fix as a denied claim.

14 chapters4 interactive toolsFigures verified Oct 2026

Chapter 01

The big picture

Patient access is the front end of the revenue cycle: scheduling, pre-registration, registration, insurance verification, authorization, patient estimates, financial counseling and point-of-service collection. Financial clearance is the outcome those steps are meant to produce: before the service is delivered, the organization knows who the patient is, who will pay, in what order, how much the patient owes, and that every notice the rules require has been given.

The work looks clerical and it is anything but. A member ID with a transposed digit, a dependent registered under the wrong subscriber, a Medicare patient whose working spouse's plan was never recorded, an outpatient who never got the notice that would have let the hospital bill her: each becomes a denial, a write-off or a compliance finding downstream, and each was cheapest to catch at the desk. The 2026 rules add pressure from the other direction. Price transparency enforcement, good faith estimates, Medicare notice updates and Medicaid eligibility changes all land first on the patient access team.

Why it matters in numbers

Denials start here

50% and 32%

In Experian Health's 2025 State of Claims survey, half of providers named missing or inaccurate data as a top cause of denials, and 32% named flawed patient registration data. 41% said their denial rate is 10% or higher.

The patient is a payer

$1,886 deductible

Average single-coverage deductible for workers who have one in the KFF 2025 Employer Health Benefits Survey. 34% face a deductible of $2,000 or more, and 33% are in a high-deductible plan. Collecting that money starts at access.

Estimates are catching on

45% got an estimate

Share of patients who received a cost estimate before care in Experian's 2026 State of Patient Access survey, up from 41% a year earlier. Those whose final bill was "much more" than the estimate fell from 44% to 26%.

Who is involved

Scheduler: Takes the order or the request, finds the slot, and starts the record. The first chance to capture insurance and to flag that an authorization or an estimate will be needed.
Pre-registration and financial clearance: A central team that works scheduled encounters days ahead: verifies eligibility, obtains authorization, builds the estimate, screens for assistance, and calls the patient. Often called pre-services or pre-access.
Registrar / patient access representative: The person at the desk, in the emergency department, or on the admitting floor who confirms identity, scans the card and ID, collects signatures, asks the MSP questions and takes the payment.
Financial counselor: Screens uninsured and underinsured patients for Medicaid, marketplace coverage, disability, crime victim and other programs, and for the hospital's financial assistance policy. Sets up payment plans.
Health information management (HIM): Owns the master patient index (MPI): merges duplicates, resolves overlays, and sets the identity rules registrars must follow.
Utilization review and case management: Decide inpatient versus observation status and trigger the Medicare notices (MOON, IM, HINN) that hang on that decision.
Billing and denial management: Live with the result. Their denial data is the feedback loop that tells access what to fix.
Patient: Has rights at every step: to a medical screening exam before any payment question in an emergency, to a good faith estimate if self-pay, to the Medicare notices, to financial assistance screening, and to be billed only what the plan says they owe.

What goes wrong when it is skipped

Eligibility and identity denials

CARC 31 (patient cannot be identified as our insured), 140 (ID and name do not match), 27 (coverage terminated), 22 (another payer is primary). Correctable, but each costs a resubmission and weeks of delay.

Unbillable balances

A Medicare service without a valid ABN is the provider's loss (modifier GZ). A QMB patient billed for cost sharing must be refunded. A self-pay patient who never got a good faith estimate can dispute a bill $400 or more above it.

Patient balances that never arrive

Roughly a quarter of patient payments are collected at the point of service, according to Kodiak Solutions' 2026 tracking. The rest goes to statements, where collection rates fall with every cycle.

Chapter 02

Scheduling and order management

Scheduling is where financial clearance gets its lead time. A visit scheduled ten days out can be verified, authorized, estimated and counseled before the patient arrives. A walk-in gets none of that. The scheduling conversation is therefore the first registration, and the order behind it is the first claim.

What a complete order contains

Element	Why access needs it	When it is missing
Ordering provider and NPI	The 837 carries the referring or ordering provider (loop 2310A). Payers deny when the orderer is not enrolled or not in network.	Hold the order; a verbal order from "the clinic" is not an order.
Service, CPT/HCPCS and laterality	Drives the authorization lookup, the estimate, the ABN decision and the slot length.	Schedulers guess; the auth is obtained for the wrong code.
Diagnosis (ICD-10-CM)	Medical necessity edits (NCDs, LCDs, payer policies) compare diagnosis to service before and after the claim.	The ABN cannot be evaluated; the auth request lacks the indication.
Priority and clinical urgency	Sets the clearance deadline and whether an expedited auth applies.	Routine requests marked urgent and vice versa.
Setting	Office, hospital outpatient, ASC, inpatient. Changes the price, the auth and the notices.	Site-of-care redirects and surprise facility fees.
Signature and date	Medicare requires a signed order (or an authenticated electronic order) for diagnostic tests and DME.	Post-payment audit findings and recoupment.

Scheduling workflow with clearance built in

1
Identify, then search Every call
Name, date of birth and one more identifier (phone, address, last four of SSN, or MRN) before creating anything. Search the MPI with the name spelled several ways. Creating a record is the single easiest way to make a duplicate.
2
Capture the coverage as stated Every call
Payer, plan name, member ID, group, subscriber name and date of birth, and whether anything changed since the last visit. Ask about a second plan and, for Medicare patients, about current employment. Offer a secure photo upload of the card.
3
Run eligibility in real time Scheduled visits
A 270/271 while the patient is on the line resolves most "which plan" questions at once. An inactive response is a reason to ask more, not to hang up.
4
Flag the clearance tasks At booking
The scheduling system should set work-queue flags from the service and payer: authorization needed, estimate due, self-pay (good faith estimate clock starts), Medicare ABN review, prior balance to discuss, interpreter needed.
5
Set expectations Before hanging up
Tell the patient what to bring, what will be collected and how to reach financial counseling. A pre-service call that mentions the amount due is the strongest predictor of a payment at check-in.
6
Pre-register and confirm 1–3 days before
Digital pre-registration (demographics, insurance photos, consents, estimate acceptance, payment) turns check-in into a confirmation. Reminders with a cost estimate attached reduce no-shows and surprises.

Measure the lead time

HFMA's MAP Keys for patient access include the pre-registration rate (encounters pre-registered ÷ scheduled encounters) and the insurance verification rate (verified ÷ registered encounters). Track both daily by department. A low pre-registration rate is usually a scheduling-template problem, not a staffing problem.

Emergency departments are different

Under EMTALA (42 CFR 489.24(d)(4)) a hospital may not delay the medical screening examination or stabilizing treatment to ask about insurance or payment, and may not seek authorization until screening is complete and stabilization has begun. Reasonable registration that does not delay care is allowed. Train ED registrars on the order of operations and never let a "financial conversation" happen before triage.

Order management for referred services

Inbound referrals

Intake queue

Faxed and electronic referrals (CCD, Direct messages, FHIR ServiceRequest) land in a work queue. Each needs a valid order, insurance, and a decision within a service standard (often 1 to 2 business days) before the patient is called.

Standing and recurring orders

Expiration dates

Therapy plans of care, infusion series, dialysis and recurring labs run on orders with end dates and visit counts. Access should see the remaining visits and the plan-of-care recertification date, and the MSP questions must be refreshed every 90 days for recurring Medicare outpatients.

Order-to-schedule reconciliation

No orphan orders

Compare signed orders with scheduled appointments weekly. Orders never scheduled are lost care and lost revenue; appointments without an order are claims that will be audited.

Chapter 03

Registration and identity

Registration answers two questions: who is this person, and have we seen them before? Everything else in the record, clinical and financial, attaches to the answer. The enemies are the duplicate (one person, two records) and the overlay (two people, one record). The first splits a history and bills under the wrong insurance; the second is a patient-safety event.

The master patient index

MPI / EMPI: The master (or enterprise master) patient index: the table of every person the organization has registered, keyed by medical record number, with the demographic traits used to match them. The EMPI links MRNs across facilities and systems.
Matching algorithm: Deterministic rules (exact match on name, DOB, sex, SSN) or probabilistic scoring across many traits. Scores above a threshold auto-link; a middle band goes to HIM for review; below the band, a new record is allowed.
Duplicate: Two MRNs for one person, usually created when a search failed (nickname, maiden name, transposed DOB) and the registrar clicked "new patient." Merged by HIM after review.
Overlay: One MRN holding two people's data, usually from selecting the wrong search result (same name and DOB, or a parent and child). Harder to fix and far more dangerous: allergies, results and insurance are mixed.
Overlap: One person with different MRNs in different facilities of the same system, linked (or not) in the EMPI.
Naming conventions: House rules for hyphens, apostrophes, suffixes, two last names, legal versus preferred names, and newborns (Boy/Girl plus mother's last name, replaced after naming). Consistency is what makes matching work.

The registration conversation

1
Ask open questions Identity
"Please tell me your full name and date of birth," never "Are you Jordan Doe, born April 12, 1985?" Confirm with a photo ID when policy requires it and with two identifiers every time, matching Joint Commission's patient identification goal.
2
Search before you create MPI
Search by name and DOB, then by DOB alone, then by phone or SSN. Look at the candidates. A record with a maiden name and an old address is still the same person.
3
Verify, don't retype Demographics
For existing patients, read back address, phone, email, emergency contact and employer and change only what changed. Each re-keying is a chance to introduce a typo that breaks a statement address or a claim.
4
Capture the legal and the preferred Demographics
Legal name as the payer has it (claims match on it); preferred name and pronouns for care; sex as on the insurance record and gender identity as the patient states it, in the fields designed for each.
5
Scan, then key Documents
Scan the ID and both sides of every insurance card. OCR fills the fields; the registrar checks them against the image. The scan is the evidence when a payer says the ID was wrong.
6
Guarantor and relationship Financial
Who gets the bill (self, parent, spouse) and who holds the insurance (subscriber) are two different questions with two different fields. Relationship codes on the 837 (SBR02 and PAT01) come from here.

Fields that break claims

Field	Rule	Typical error	Result on the claim
Patient name	Exactly as on the insurance record; no nicknames; suffix in its own field	"Bill" for William; hyphen dropped; suffix appended to last name	CARC 140 / RARC N382; eligibility 271 returns AAA 72 (invalid member)
Date of birth	Verified against ID; month and day in the right order	Transposed digits; a parent's DOB on the child	CARC 31 or 140; overlay risk
Sex	As on the insurance record for the claim; gender identity captured separately	Defaulted field never changed	Sex-specific procedure edits; eligibility mismatch
Address and phone	USPS-standardized; verified each visit	Old address; mobile number missing	Returned statements; no digital outreach; address edits on the 837
Subscriber and relationship	Subscriber's name, DOB and ID when the patient is a dependent	Child registered as self; spouse as subscriber when the patient is	CARC 31; claim pays to the wrong accumulators
Guarantor	Adult responsible for the bill; emancipated minors and adult children are their own guarantor	Parent left as guarantor of a 30-year-old	Statements to the wrong person; HIPAA complaint
Employer and employment status	Needed for MSP and for workers' compensation	Blank or "retired" for a working 70-year-old	Medicare billed primary when the employer plan was primary
Accident indicator	Auto, employment, other, with date and state	Not asked at all	CARC 22 (COB) or MSP rejection; liability insurer never billed

Overlays are a safety event

Treat a suspected overlay like a medication error: stop, report to HIM, and do not use the record until it is split. The AHIMA survey of 815 HIM professionals found 73% work on duplicate mitigation at least weekly; overlays are rarer but every one is dangerous. Never "fix" an overlay by editing the demographics over the other person.

Medical identity theft

A patient using someone else's card creates an overlay and a false claim. Ask for photo ID, compare the photo, and compare the signature to prior consents. If the eligibility response shows a different DOB or sex than the person in front of you, escalate rather than override. Document the discrepancy; do not confront the patient about fraud at the desk.

Consents collected at registration

Consent to treat

General consent for examination and treatment. Distinct from informed consent for a procedure, which the clinician obtains. Renewed per visit or per policy period (often annually for outpatient series).

Financial agreement and assignment of benefits

The patient agrees to pay what the plan does not, and assigns insurance benefits to the provider so the payer pays the provider directly. This is what makes box 12 and 13 of the CMS-1500 ("signature on file") true.

Notice of privacy practices

HIPAA requires giving the notice at the first service and making a good-faith effort to get a written acknowledgment. The acknowledgment, or the documented refusal, is kept six years.

Release of information

Authorizes sending claim information to the payer (CLM09 on the 837) and, separately, any disclosure beyond treatment, payment and operations, such as to a family member or an employer.

Advance directive inquiry

Hospitals and other Medicare providers must ask whether the patient has an advance directive and document the answer (Patient Self-Determination Act, 42 CFR 489.102). Asking is required; having one is not.

Language and accessibility

Record the preferred language and the need for an interpreter or accommodation (Section 1557, ADA). Consents signed without a qualified interpreter are not informed consents.

Chapter 04

Insurance capture and verification

The insurance record has three parts that must agree: what the card says, what the patient says, and what the payer's eligibility system returns. Registration captures the first two; verification tests them against the third. The eligibility tutorial covers the 270/271 in depth; this chapter covers the capture workflow and what to do with the response.

Card scanning and what to key

Capture

Scan both sides, every visit

Card scanners and phone uploads with OCR read the member ID, group, plan name, payer ID and phone numbers. The registrar's job is to check the extracted fields against the image, not to type them. Date-stamp the scan; a card from 2024 is not proof of 2026 coverage.

Interpret

What the card does not say

Whether the plan is active, whether the patient is still a dependent, which network applies at your site, the deductible met to date, and whether another plan is primary. Only the 271 or a call answers those.

Payer selection

Pick the plan, not the logo

The registration system's payer list maps each plan to a payer ID, an address and a set of billing rules. Choosing "Northwind PPO" when the card says "Northwind Medicare Advantage" sends the claim to the wrong product with the wrong rules. Build the list with the plan name as printed and retire old entries.

Order of payers

Primary, secondary, tertiary

Record every plan with its COB order and the reason (MSP rule, birthday rule, court order, active versus COBRA). The 837 carries the order in SBR01 and the other payers in loop 2320. Wrong order is CARC 22 and a resubmission.

Verification: reading the 271 for clearance

271 element	What it tells access	Action
`EB1` Active coverage, with dates (DTP346/347)	Coverage is active for the plan on the date of service	Save the response to the encounter as proof; schedule
`EB*6` Inactive, or `AAA` rejection codes (72 invalid member ID, 73 invalid name, 71 DOB mismatch)	The identifiers do not match, or coverage ended	Re-check the card and spelling; ask the patient; search for new coverage
`EBC`, `EBG` with amounts and time qualifier (23 remaining, 29 ... per year)	Deductible and out-of-pocket maximum, total and remaining	Feed the estimate calculator (chapter 07)
`EBA` (coinsurance %), `EBB` (copay $)	Cost-sharing rules by service type (EB03) and in/out of network (EB12)	Use the line that matches your service type and network status
`EB*R` Other or additional payer, with NM1 loop	The payer knows of another plan, often primary	Add the other plan; run its eligibility; set COB order
`EBU`, `EBV`, `EB*W` (managed care contact, prior authorization or PCP)	HMO assignment, PCP, carve-outs and authorization requirements	Route to the authorization queue; check the PCP referral
`MSG` free text	Plan-specific instructions: "Medicare is primary," "Subscriber terminated 09/30/2026," "QMB"	Read every MSG; it often carries the information the structured segments cannot
Medicare HETS: `EB*R` with the MA plan's name and contract number, QMB indicator, MSP data	The patient has a Medicare Advantage plan, a Medicaid dual status, or an MSP record	Bill the MA plan, not Medicare; apply the QMB billing prohibition; reconcile MSP against the questionnaire

Coverage discovery and other-coverage search

Patients forget plans, do not know a spouse added them, or do not realize a Medicaid application was approved. Discovery tools query payers in batches with name, DOB and sometimes SSN to find coverage the patient did not report. Run them at registration for self-pay patients, before statements go out, and before an account is sent to bad debt or charity. The hit rate is highest for Medicaid (retroactive eligibility), Medicare Advantage, and commercial plans picked up after a job change.

Retroactive Medicaid

Medicaid eligibility can be backdated: 90 days before the application month in most states today, falling to one month for expansion adults and two months for others from January 1, 2027 under the 2025 reconciliation law. Discovery after discharge still pays, but the window is closing.

Medicare for the self-pay patient

Anyone 65 or older or on Social Security disability for 24 months is likely Medicare-eligible. HETS tells you whether they are enrolled and in which parts and plans. Many "self-pay" seniors turn out to have a Medicare Advantage plan.

The 2026 marketplace

With enhanced premium tax credits gone after 2025, effectuated marketplace enrollment fell to 19.2 million in February 2026 from 21.8 million a year earlier (KFF). Expect more patients whose "insurance" lapsed for non-payment; re-verify every visit.

The 2026 verification stack

Real-time 270/271: Required of every HIPAA payer; 96% of medical plan eligibility transactions were fully electronic in the 2024 CAQH Index. Provider cost: about $2.00 electronic versus $8.57 manual per inquiry, with a $11.7 billion annual savings opportunity still on the table.
Batch re-verification: Run the whole schedule 1 to 3 days ahead and again the morning of service. Catches terminations at month end and plan changes in January.
Payer portals: Needed for details the 271 omits (accumulators by family member, authorization lists, PCP). Save screenshots with dates; a portal view is evidence in a dispute.
FHIR Patient Access and Payer-to-Payer APIs: CMS-regulated payers must expose claims, encounter and coverage data through FHIR APIs, with Provider Access APIs due January 1, 2027 under CMS-0057-F. Expect eligibility and benefit detail to arrive inside the EHR rather than from a separate lookup.
Phone verification: The last resort, with the date, time, representative name and reference number recorded in the encounter. "Verification is not a guarantee of payment" is printed on every response; the record of the call is still your best evidence.

Verification checklist for a scheduled visit

Plan active on the date of service, under the product named on the card, with the patient (not just the subscriber) listed as covered.
Your site is in network for that product. A carrier's PPO network and its exchange network are not the same list.
Other coverage identified and ordered: MSP questions for Medicare patients, birthday rule for children, COBRA versus active, auto or workers' compensation for accidents.
Benefits captured for the service type: deductible remaining, coinsurance, copay, out-of-pocket remaining, visit limits.
Authorization or referral status known and the number on the encounter.
Flags noted: QMB or other Medicaid dual status, HMO PCP assignment, carve-out vendors, prior balance.
Evidence saved: 271 response or portal screenshot attached to the encounter with the date verified.

Chapter 05

Medicare Secondary Payer and other-coverage discovery

Medicare is the payer of last resort whenever another insurer is legally responsible. The Medicare Secondary Payer (MSP) rules say when that is true, and the MSP questionnaire is how providers find out. Billing Medicare as primary when it is secondary is an overpayment that must be returned; billing it secondary when it is primary delays payment for months. The questions take two minutes and they are required.

When Medicare is secondary

Situation	Medicare is secondary when…	Primary payer	MSP type (SBR05 / value code)
Working aged	The patient is 65 or older and covered by a group health plan through their own or a spouse's current employment, and the employer has 20 or more employees	Employer group health plan	12
Disability	The patient is under 65, entitled by disability, and covered by a large group health plan through their own or a family member's current employment, and the employer has 100 or more employees	Large group health plan	43
End-stage renal disease	The patient has any group health plan coverage (including retiree or COBRA) and is within the 30-month coordination period that starts with ESRD-based Medicare eligibility	Group health plan, for 30 months	13
Workers' compensation	The service treats a work-related injury or illness	WC carrier (or the employer)	15
No-fault	The service treats an injury from an auto or other accident covered by no-fault, medical payments or PIP coverage, regardless of fault	No-fault insurer	14
Liability	Another party may be legally responsible for the injury (auto, premises, product, malpractice)	Liability insurer or settlement	47
Federal Black Lung	The service treats a lung condition covered by the Black Lung program	Department of Labor	41
Veterans Affairs	The VA authorized the care; the veteran chooses one program per service	VA	42

Current employment

Active, not retired

Retiree coverage, COBRA (except in ESRD cases) and plans of employers under the size threshold leave Medicare primary. "Current employment status" includes some leaves of absence and disabled workers still carried as employees. The question is about the employer plan's basis, not whether the patient feels retired.

Employer size

20 and 100

Counted as employees on the payroll for 20 or more weeks in the current or preceding year. Two small employers in a multi-employer plan combine if any one of them meets the threshold. When in doubt, record the employer's name and let the benefits coordination contractor decide.

Conditional payment

120 days

For liability and no-fault, the provider bills the insurer first. If it has not paid within 120 days (the prompt-pay period), Medicare may be billed for a conditional payment, which Medicare recovers from the settlement. Workers' compensation claims that are contested can be billed to Medicare with a note that the claim is disputed.

The MSP questionnaire

CMS's model questionnaire (Medicare Secondary Payer Manual, chapter 3, section 20.2.1) has three parts: accidents and special programs (Black Lung, workers' compensation, no-fault, liability), entitlement and group health plan coverage (age, disability, employer size), and ESRD. Providers must ask the questions for every inpatient admission, outpatient encounter or start of care; for recurring outpatient services the answers must be re-verified every 90 days. Access to the Common Working File or a 271 does not remove the duty to ask, though a provider may ask whether anything changed if it has a complete questionnaire on file. Keep the answers for 10 years after the date of service. Medicare Advantage members are exempt; their plan coordinates benefits.

Other-coverage rules that are not MSP

Birthday rule: For a child covered by both parents' plans, the plan of the parent whose birthday falls earlier in the calendar year is primary (NAIC model; most states and plans). Court orders and custody arrangements override it.
Active over COBRA, employee over dependent: A plan covering the patient as an active employee pays before one covering them as a dependent or COBRA continuant. Medicaid is always last; TRICARE is secondary to all except Medicaid and specific programs.
Medicare Advantage: The MA plan stands in Medicare's place and applies the same MSP rules itself. Bill the MA plan, never Traditional Medicare, for the months of enrollment.
Dual eligibles: Medicare primary, Medicaid secondary. QMB and other Medicare Savings Program enrollees cannot be billed for Medicare cost sharing at all (chapter 08).
Benefits Coordination & Recovery Center (BCRC): CMS's contractor that holds the MSP record. When the Common Working File shows an MSP occurrence the patient says has ended, the patient or employer must call the BCRC to update it; the provider cannot override it on a claim.

Chapter 06

Consents and Medicare notices

Medicare beneficiaries have a statutory right to know, before they get care, when Medicare is not expected to pay and when a covered stay or service is ending. Each situation has its own notice, form number and clock. Deliver the right one on time and the patient can be billed; miss it and the cost is the provider's.

Notice	Form	Who gives it	When	What it does
Advance Beneficiary Notice of Non-coverage (ABN)	CMS-R-131, revised 2026 (OMB approval March 13, 2026; mandatory from May 12, 2026; expires March 31, 2029)	Physicians, suppliers, labs, hospital outpatient departments, home health and hospice for Part B and certain Part A services	Before the service, far enough ahead for the patient to decide; never in an emergency	Shifts liability for a service Medicare is expected to deny as not reasonable and necessary. Voluntary for statutorily excluded services.
Medicare Outpatient Observation Notice (MOON)	CMS-10611, updated 2026 (mandatory from April 20, 2026; expires February 28, 2029)	Hospitals and critical access hospitals; MA plans' hospitals too	No later than 36 hours after observation services begin, to any patient receiving observation for more than 24 hours	Explains outpatient status and its consequences: Part B cost sharing, self-administered drugs, no SNF qualifying stay. Oral explanation and signature required.
Important Message from Medicare (IM)	CMS-10065	Hospitals, for every Medicare inpatient (Traditional and MA)	Within 2 calendar days of admission, and a follow-up copy no more than 2 calendar days before discharge	Discharge appeal rights through the QIO (42 CFR 405.1205). A short stay where the first copy falls within 2 days of discharge needs no second copy.
Detailed Notice of Discharge (DND)	CMS-10066	Hospital or MA plan	Only when the patient asks the QIO for an expedited review	Explains why the hospital and plan believe the stay is no longer covered.
Notice of Medicare Non-coverage (NOMNC)	CMS-10123 (January 2025 version)	SNFs, home health, hospice, CORFs; Traditional and MA	At least 2 calendar days before covered services end	Right to a fast QIO appeal of the end of services (42 CFR 405.1200). The DENC (CMS-10124) follows if the patient appeals.
Hospital-Issued Notices of Non-coverage (HINN)	HINN 1, 10, 11, 12	Hospitals, inpatient	Before admission or at the point care becomes non-covered	HINN 1 for a non-covered admission or pre-admission; HINN 10 when the hospital asks the QIO to review continued stay; HINN 11 for non-covered items during a covered stay; HINN 12 for a continued stay after the QIO agrees discharge is appropriate.
SNF ABN	CMS-10055	Skilled nursing facilities, Part A	Before a Part A stay or service the SNF expects Medicare not to cover	Shifts liability for Part A SNF care (not a NOMNC substitute).
Medicare Change of Status Notice (MCSN)	CMS-10868	Hospitals, Traditional Medicare	When a patient is reclassified from inpatient to outpatient observation	A newer notice created after the Alexander v. Azar litigation; gives appeal rights to patients whose status was changed.

The ABN in practice

When it is required

Expected medical-necessity denial

Frequency limits exceeded (a screening earlier than the covered interval), a diagnosis the LCD does not list, experimental use, custodial care, a lab panel ordered without a supporting indication. The notifier must have a genuine reason to expect the denial; routine or blanket ABNs are not acceptable practice.

When it is voluntary

Statutorily excluded services

Cosmetic surgery, routine dental, hearing aids, most routine foot care, personal comfort items. Medicare never pays, the patient is liable with or without a notice, and an ABN given as a courtesy is reported with modifier GX. The patient need not sign.

Filling it out

Items, reason, estimate, options

Name the item or service in plain language, state why Medicare may not pay, and give a cost estimate; CMS expects it within $100 or 25% of the actual cost, whichever is greater. The patient chooses: Option 1 (bill Medicare, keep appeal rights), Option 2 (do not bill Medicare, pay now), or Option 3 (decline the service). Staff must not pre-select an option.

Keeping it

Five years, retrievable

The signed ABN stays on file for five years from discharge or completion of care (longer if state law says so) and must be produced on request. Scan it to the encounter; the modifier GA on the claim is a statement that it exists.

Liability modifiers on the claim

Modifier	Meaning	Who pays if Medicare denies
`GA`	Required ABN issued and on file; service expected to be denied as not reasonable and necessary	Patient (denial posts as PR); the patient may appeal
`GX`	Voluntary ABN issued for a statutorily excluded service (used with GY)	Patient
`GY`	Statutorily excluded or not a Medicare benefit; no ABN required	Patient; the claim produces the denial a secondary payer may need
`GZ`	Expected to be denied as not reasonable and necessary and no ABN was issued	Provider (denial posts as CO); the patient cannot be billed

Observation is an outpatient status

A patient in a hospital bed under observation is an outpatient. Part B cost sharing applies per service, self-administered drugs are generally not covered, and the days do not count toward the three-day inpatient stay that Medicare requires before covering a skilled nursing facility (a requirement MA plans may waive). The MOON exists so the patient hears this from the hospital, not from the bill.

Notices are not waivers for other payers

The ABN is a Medicare instrument. Commercial plans may allow a plan-specific waiver when the contract permits patient billing for non-covered services, and Medicaid generally prohibits billing enrollees for covered services at all. Medicare Advantage plans do not use the ABN; the route to patient liability is a pre-service organization determination and the plan's own denial notice.

Chapter 07

Price estimates and price transparency

Three separate rules push prices to the front of the encounter: the No Surprises Act's good faith estimate for uninsured and self-pay patients, the hospital price transparency rule that makes negotiated rates public, and the Transparency in Coverage rule that makes plans run cost estimators. A patient estimate combines all three with the one thing none of them has: this patient's accumulators from today's 271.

Good faith estimates (No Surprises Act)

Who and when

Uninsured and self-pay patients

Anyone without coverage, or who asks you not to bill their plan, must get a written good faith estimate (GFE) when they schedule or on request. Due within 1 business day if the service is scheduled at least 3 business days ahead, within 3 business days if scheduled at least 10 business days ahead or when a price is requested without scheduling. The convening provider or facility is responsible.

What it contains

Items, codes, expected charges

A list of the items and services the convening provider reasonably expects, with diagnosis and service codes and the expected charge for each, in plain language, plus disclaimers and dispute rights. Since 2023 it was meant to include co-providers and co-facilities (anesthesia, pathology); HHS continues to exercise enforcement discretion on that element until it issues rules.

The $400 rule

Patient-provider dispute resolution

If the final bill from a provider or facility is at least $400 more than that provider's GFE, the patient can start the PPDR process within 120 calendar days of the bill, for a $25 administrative fee. While it is pending the provider may not send the bill to collections or charge late fees. The reviewer can set the amount owed at the estimate.

Still coming

Insured patients and the AEOB

The statute also requires a GFE to the plan and an advanced explanation of benefits (AEOB) to insured patients. As of 2026 that part remains unimplemented pending rulemaking, so the insured-patient estimate is a service standard, a state requirement in some states, and a collections tool, not a federal duty.

Hospital price transparency (45 CFR Part 180)

Requirement	Detail	Status 2026
Machine-readable file of standard charges	Gross charge, discounted cash price, payer-specific negotiated charges, de-identified minimum and maximum, for every item and service, in the CMS template	In effect since January 1, 2021; template mandatory since 2024
Shoppable services display	300 shoppable services in a consumer-friendly list, or a price estimator tool that satisfies the requirement	In effect
Allowed-amount data	From January 1, 2026: replace the "estimated allowed amount" with the median, 10th and 90th percentile allowed amounts and the count behind them, derived from 835 remittance data over the prior 12 to 15 months, when a negotiated charge is a percentage or algorithm	Effective January 1, 2026; enforced from April 1, 2026
Attestation and accountability	Attest that the file is true, accurate and complete; include all payer-specific charges expressible in dollars; name the CEO, president or senior official responsible; list the hospital's Type 2 NPIs	Effective January 1, 2026
Penalties	$300 per day for hospitals with 30 or fewer beds; $10 per bed per day above 30, up to $5,500 per day. From 2026 a 35% reduction for hospitals that waive the ALJ hearing (not for a missing file or missing shoppable display)	28 hospitals fined since enforcement began in 2022; 519 warning letters issued between April and early June 2026

Transparency in Coverage

The plan's estimator

Group and individual plans must post in-network rate and out-of-network allowed-amount files (since July 2022) and run an internet cost-comparison tool: 500 items from plan years starting 2023, all items from 2024. Patients arrive with the plan's number; your estimate should explain any difference (site, codes, accumulators).

Hospital price estimator tools

Self-service, with limits

Most hospitals meet the shoppable-services requirement with an online estimator. It is only as good as the chargemaster mapping behind it, and it cannot see the patient's deductible unless it runs a 271. Pair it with a staffed estimate line.

State laws

Stricter in places

Several states require estimates to insured patients on request, cap how far a bill may exceed an estimate, or tie collection rights to compliance with transparency rules. Check your state's hospital billing statute before relying on the federal floor.

Building the patient estimate

An estimate is arithmetic on four numbers: the allowed amount for the service under the patient's plan (from the contract or the transparency file), the deductible remaining, the cost sharing for that service type (copay, coinsurance), and the out-of-pocket maximum remaining. The 271 supplies the accumulators; the contract supplies the allowed amount; the order supplies the codes. Below is a fictional 271 excerpt for Jordan Doe's plan, followed by the calculator that turns it into a number.

EB*C*IND*30**23*2000***Y~ deductible, in network, calendar year: $2,000 EB*C*IND*30**29*1400***Y~ deductible remaining: $1,400 EB*G*IND*30**23*5000***Y~ out-of-pocket maximum: $5,000 EB*G*IND*30**29*4400***Y~ out-of-pocket remaining: $4,400 EB*A*IND*30*****.2**Y~ coinsurance 20% after deductible, in network EB*B*IND*98*****40**Y~ copay $40 for office visits (service type 98)

Patient estimate calculatorAllowed amount × accumulators from the 271. For self-pay, the good faith estimate and the $400 dispute threshold.

Patient type

Insured, in network Uninsured or self-pay (GFE)

Gross charge $

Contracted allowed amount $

Deductible remaining $

Copay for this service $

Coinsurance %

Out-of-pocket remaining $

Self-pay discount %

Prior balance $

Estimate hygiene

Date it and source it. Record the 271 date, the accumulators used and the fee source. An estimate is a snapshot; a surgery two weeks later may hit a different deductible.
Name the uncertainty. Add-on codes, implants, pathology and anesthesia are the usual reasons a bill differs from an estimate. Say so in writing.
Give it in the patient's channel. Experian's 2026 survey found 71% of patients who got an estimate found it easy to understand; estimates delivered to mobile devices rose sharply. Text and portal delivery with a pay link converts better than a mailed letter.
Keep the GFE for self-pay patients with the date sent; it is the document the dispute process will compare against.

Chapter 08

Point-of-service collections

The best time to collect a patient balance is before the patient leaves, and the second-best is before they arrive. Once a balance moves to statements, every cycle collects less. Point-of-service (POS) collection is not aggressive billing; it is telling the patient the amount early, offering ways to pay it, and asking.

What the numbers say

POS share

About a quarter

Kodiak Solutions' hospital data put the point-of-service collection rate at 24.8% in the first quarter of 2026, up from 22.7% a year earlier, with point-of-service cash about 30% of all patient payments. The share varies by payer type: highest for Medicaid fee-for-service and Medicare Advantage patients, lowest (about 15%) for Traditional Medicare, whose balances mostly flow to supplemental plans.

Pre-service is growing

16% to 21%

In HFMA's 2026 survey with PayZen, pre-service collections rose from 16% of self-pay collections in 2025 to 21% in 2026, and 91.5% of organizations now encourage, require or collect a payment before service.

Required, but flexible

17.1% require up-front payment

Of organizations that formally require payment before elective care, 68% proceed anyway when the patient cannot pay (up from 41.7% a year earlier). A "requirement" is a conversation starter; care is rarely withheld.

What can be collected at the point of service

Amount	Basis	Notes
Copay	Fixed amount on the card or the 271 for the service type	Contractually required to be collected by most plans; waiving it routinely violates the contract and, for federal programs, the Anti-Kickback Statute and beneficiary inducement rules
Deductible and coinsurance estimate	Chapter 07 calculation	Collect as an estimate, deposit or pre-payment, refunded if the adjudicated amount is lower. State the refund policy in writing
Prior balances	Open self-pay balances on the guarantor account	Mention them; do not condition today's care on them except under a written policy that excludes emergencies and complies with 501(r)
Self-pay charges	Good faith estimate, less any self-pay discount or financial assistance	Screen for assistance before collecting; a patient who qualifies for charity care should not be paying a deposit
Non-covered services	ABN Option 2, cosmetic or elective services	Payment in full or a signed plan before the service
Never	Medicare cost sharing from a QMB; amounts a Medicaid plan covers; emergency department payment before screening; balances above the in-network cost sharing for No Surprises Act protected services	Each is a compliance violation, not a collections judgment call

The collection conversation

1
Prepare the number Pre-service
Registrars collect what they can see. The estimate, the copay and the prior balance must be on the check-in screen, with the 271 behind them. A registrar guessing at a copay collects nothing.
2
State the amount as a fact Check-in
"Your plan sets a $60 specialist copay, and based on your remaining deductible today's visit is estimated at $240. How would you like to take care of that?" Not "Would you like to pay anything today?"
3
Offer the ways to pay Check-in
Card, digital wallet, HSA card, text-to-pay link, payment plan, card on file with a capped auto-charge after adjudication. Every option has a script; the registrar picks, not the patient's silence.
4
Pivot to help, not pressure When the answer is no
"If the amount is a concern, we have a financial counselor who can check whether you qualify for assistance or set up a plan." The policy decides whether an elective service is rescheduled; the registrar never does it alone.
5
Receipt, posting, reconciliation Same day
Every payment gets a receipt with the account number and purpose (copay, deposit toward estimate), posts to the encounter, and balances to the cash drawer and the merchant report at close of day.

Card on file, done properly

Store card data only in the payment processor's vault (tokenization), with the patient's signed authorization that states the maximum amount, the trigger (after the plan adjudicates), and how to cancel. PCI DSS applies to any system that touches card numbers; registration screens should never hold them. Send the receipt and the explanation before charging.

Collections at the point of service are still collections

Nonprofit hospitals' financial assistance policies (501(r)) govern the whole encounter: the plain-language summary must be offered, and no extraordinary collection action may be taken before reasonable efforts to determine eligibility. Deferring or denying care because of a prior unpaid bill counts as an extraordinary collection action under the IRS rules unless the policy and notice requirements are met.

Measuring collections

POS cash collections (HFMA MAP Key PA-7): Patient point-of-service payments ÷ total self-pay cash collected. The share collected before the patient leaves.
Pre-service collection rate: Dollars collected before the date of service ÷ dollars estimated for scheduled encounters. Tracks whether the pre-service call is turning estimates into payments.
Estimate accuracy: Adjudicated patient responsibility ÷ estimated patient responsibility, by service line. Within 10% is a common internal target; outliers point to bad fee mapping or stale accumulators.
Collection rate by registrar: Collected ÷ collectible for each registrar, used for coaching. Pair it with the ask rate (encounters where an amount was requested) so the measure rewards asking, not just lucky patient mixes.
Conversion rate of uninsured to a funding source (PA-6): Uninsured patients converted to a third-party payer ÷ uninsured encounters. The financial counseling yield (chapter 09).

Chapter 09

Financial counseling, Medicaid screening and the clearance workflow

Financial clearance is a workflow, not a form. Scheduled encounters move through a queue of tasks that must finish before the patient arrives; uninsured and underinsured patients move through a second queue that looks for a payer or an assistance program. Both queues have owners, deadlines and a definition of "cleared."

The pre-service financial clearance workflow

1
Encounter scheduled Day −10 or earlier
The clearance record is created with the order, the service codes, the payer and the flags (auth, estimate, self-pay, Medicare notice review). Due date = date of service minus the clearance standard, commonly 2 to 3 business days.
2
Eligibility and benefits verified Day −7 to −3
271 run, other coverage searched, COB order set, accumulators captured, network status confirmed. Failed verification routes to a phone call to the patient the same day.
3
Authorization and medical necessity Day −7 to −2
Auth submitted and tracked (see the prior authorization tutorial); for Medicare, the diagnosis checked against the LCD and the ABN decision recorded.
4
Estimate built and delivered Day −5 to −2
Estimate from the calculator, GFE for self-pay patients within the statutory window, sent through the patient's preferred channel with a pay link.
5
Financial counseling where needed Day −5 to −1
Self-pay, high-balance, prior-balance and underinsured patients get a counselor call: assistance screening, Medicaid or marketplace application, payment plan, or a deposit agreement.
6
Cleared, or escalated Day −2
Status set to cleared when every task is done, or to "at risk" with a reason (no auth, no coverage, estimate unpaid) that the department and the scheduler can see. Elective services at risk are rescheduled under policy; emergencies and urgent care proceed regardless.
7
Arrival Day 0
Check-in becomes confirmation: identity, card, MSP, consents, ABN if flagged, payment. Walk-ins and ED patients run the same steps compressed, after screening.

Finding a payer for the uninsured

Program	Who may qualify (2026)	Access team action	Notes
Medicaid (expansion adults)	Adults 19–64 with income up to 138% of the federal poverty level in expansion states: $22,025 for one person in 2026 (FPL $15,960 plus $5,680 per additional person)	Screen every self-pay patient; file the application or refer to an enrollment vendor; request retroactive coverage	From December 31, 2026 states must apply work or community engagement requirements (80 hours a month, with exemptions) and redetermine expansion adults every six months; retroactive coverage shrinks to one month from January 1, 2027
Medicaid (other groups) and CHIP	Children, pregnant women, parents, aged, blind and disabled, at state-specific income limits	Same screening; pregnancy and disability pathways often have higher limits	Presumptive eligibility lets qualified hospitals grant temporary Medicaid on the spot in many states
Marketplace coverage	Anyone without affordable employer coverage; subsidies on a sliding scale, smaller since enhanced credits expired after 2025	Refer during open enrollment or a special enrollment period (loss of coverage, move, birth)	Coverage starts the next month at the earliest; it does not cover today's visit
Medicare	Age 65+, 24 months of disability benefits, ESRD or ALS	Check HETS; refer to Social Security for enrollment; screen for Medicare Savings Programs and Extra Help	Retroactive Part A entitlement is possible for the aged; Part B is not
Disability (SSI/SSDI)	Patients with long-term disabling conditions, often inpatient or ED frequent users	Disability advocacy vendors or in-house specialists file and follow the claim	SSI brings Medicaid in most states; SSDI brings Medicare after 24 months
Victims of crime, COBRA, workers' compensation, VA, Indian Health Service	Situational	Ask the screening questions; each program has its own application	Crime victim compensation funds pay as payer of last resort in every state
Hospital financial assistance (charity care)	Per the hospital's financial assistance policy (FAP), typically free care below 200% FPL and discounts to 300–400% FPL; nonprofit hospitals must have one under 501(r)	Screen, apply, and use presumptive eligibility data (credit-based or public-program proxies) where policy allows	Patients eligible for assistance may not be charged more than amounts generally billed (AGB) to insured patients

2026 Medicaid pressure

More churn, shorter lookback

The 2025 reconciliation law's Medicaid provisions mean more patients will lose coverage between visits and fewer months of retroactive coverage to recover. CBO projects about 10 million more uninsured people by 2034. Screening at every visit, not just at the first, becomes the norm.

Medicare Savings Programs

QMB, SLMB, QI

Low-income Medicare beneficiaries can have Medicaid pay their premiums and, for QMB, all cost sharing. Screening Medicare patients with large balances for MSP enrollment turns bad debt into crossover claims.

Payment plans

Interest-free, affordable, automatic

Offer a plan at the counter and on the statement: zero interest, a term tied to the balance, auto-pay, and a path to assistance if the patient cannot make the minimum. A plan that is set up is worth more than a deposit that is refused.

Counseling the underinsured

The patient with a $4,000 deductible in January is as much a counseling case as the uninsured patient. Experian's 2026 survey found fewer than two in five patients feel confident they can pay for care and 32% say paying got harder in the last year. The counselor's job is to show the number, explain where it comes from, check whether the hospital's assistance policy applies even to insured patients (many do, by income), and set up a plan the patient can keep. Document every conversation; the record is what proves "reasonable efforts" under 501(r) and what answers a complaint months later.

Clearance checklist

Identity confirmed against the MPI, no duplicate created Two identifiers; photo ID scanned when policy requires
Coverage verified for the date of service, with the 271 saved Plan, product, network, patient listed as covered
Other coverage searched and ordered MSP questionnaire for Medicare; birthday rule; accident questions
Authorization or referral on file, or documented as not required
Medicare notice decision made ABN issued and scanned, or reason it is not needed; MOON/IM owner identified for hospital stays
Estimate or GFE delivered and the date recorded
Assistance screening completed for self-pay and high-balance patients
Payment collected or plan agreed, receipt issued
Consents signed: treatment, financial agreement, assignment of benefits, privacy acknowledgment

Chapter 10

Registration quality and the denials it causes

Registration quality is measured two ways: by auditing registrations against source documents before the claim, and by tracing denials back to the field that caused them after it. The first is cheaper. Together they tell you which registrars, which departments and which fields need attention.

Denials that start at registration

CARC / RARC	Payer's words	Usual registration cause	Fix
`31`	Patient cannot be identified as our insured	Wrong member ID, dependent registered as subscriber, wrong payer or product selected	Re-verify; correct the subscriber loop; resubmit as a new claim if rejected, corrected claim (frequency 7) if adjudicated
`140` · `N382`	Patient/insured identification and name do not match	Nickname, hyphen, suffix in the wrong field, transposed DOB	Match the 271 exactly; fix the MPI, not just the claim
`27` / `26`	Expenses incurred after (before) coverage terminated (began)	Stale card; termination at month end missed; new plan not captured	Discovery search; bill the new plan; check timely filing on the new payer
`22` · `MA04`	Care may be covered by another payer per COB	Other coverage not captured or ordered wrongly; MSP questions skipped	Bill the primary; resubmit with the primary's adjudication (loop 2320/2330)
`109`	Claim not covered by this payer / contractor	Medicare billed when an MA plan is in force; wrong Medicaid MCO; carve-out vendor	HETS or 271 to find the right plan; redirect the claim
`16` · `N286`, `N285`	Missing or invalid referring provider	Order without an NPI; referring provider not enrolled	Complete the order; enroll or replace the referring provider
`197`	Precertification / authorization absent	Auth flag not set at scheduling; service changed	See the prior authorization tutorial; retro auth if available
`50` with `GZ`	Not medically necessary; provider liable	ABN not issued when the diagnosis did not support the service	Write-off; fix the ABN trigger in the order workflow
`24`	Charges covered under a capitation agreement or managed care plan	HMO member registered to the carrier's PPO; wrong site for the assigned network	Verify PCP and network at scheduling; redirect
`29`	Time limit for filing has expired	Claim bounced among payers because coverage was wrong from the start	Appeal with proof of timely submission to the first payer; prevent with verification

Auditing registrations

Sample

Daily, random, per registrar

Pull a random sample of yesterday's registrations per registrar (commonly 5 to 10) and compare each field to the scanned card, the ID, the 271 and the order. Score each field, not just the registration; a registration with one wrong digit in the member ID is 100% wrong for the claim but 95% right on the field count.

Weight

Not all fields are equal

Member ID, payer, subscriber, DOB and name break claims; email and emergency contact do not. Weight the scorecard so the accuracy rate reflects financial impact, and report the critical-field rate separately.

Target

98% or better on critical fields

A target of 98% accuracy on critical fields is common in access departments, with coaching below 95%. The number matters less than the trend by registrar and the specific fields that drive it.

Feedback

Same week, by name, with the fix

Errors fed back a month later as a percentage change nothing. The registrar needs the specific record, what was wrong, how to find it next time, and the denial it would have caused. Automated registration QA tools do this in real time at the desk.

Registration accuracy scorecardEnter an audit sample and the month's volume. The projections use your own assumptions for rework cost and claim value.

Registrations audited

Registrations this month

Identity errors (name, DOB, sex)

Insurance errors (payer, plan, member ID)

Subscriber / relationship errors

COB / MSP errors

Authorization / referral missing

Demographic errors (address, phone, guarantor)

Consent / notice / scan missing

Rework cost per error $

Average claim value $

Share of critical errors that deny %

Fixing the process, not the registrar

Where most registration errors come from

Payer lists. Hundreds of plan entries with ambiguous names produce wrong-payer selections. Clean the list, name plans as the cards do, and map each to the right payer ID and billing rules.
Free-text fields. Member IDs keyed by hand instead of read from the scan. Require the scan and validate the ID format against the payer's pattern.
Search habits. "New patient" created without a proper search. Force a search with at least two traits before the button is enabled.
Interrupted check-in. Emergency department and bedside registrations done under time pressure. Finish them in a quality queue before the claim drops, not after.
No feedback loop. Billing works the denial and never tells access. Route every registration-caused denial back to the registrar with the record number.
Training. New registrars learn payers for months. Pair a 30-day audit of every registration with a mentor and a payer cheat-sheet; move to sampling only after the critical-field rate holds above target.

Access KPIs worth reporting monthly

Measure	Formula	Common target
Pre-registration rate (PA-2)	Pre-registered encounters ÷ scheduled encounters	90%+
Insurance verification rate (PA-3)	Verified encounters ÷ registered encounters	98%+
Service authorization rate (PA-4, PA-5)	Encounters authorized ÷ encounters requiring authorization	98%+
Conversion of uninsured to a funding source (PA-6)	Uninsured converted ÷ uninsured encounters	Trend up
POS cash collections (PA-7)	POS payments ÷ total self-pay cash	Trend up; industry about 25%
Registration accuracy, critical fields	Fields correct ÷ fields audited	98%+
Duplicate creation rate	New duplicates found ÷ registrations	Under 1%
Front-end denial rate	Claims denied for eligibility, identity, COB or authorization ÷ claims	Under 2%
Estimate delivery rate	Scheduled encounters with an estimate sent ÷ scheduled encounters	Trend up

Chapter 11

Rules and regulations

Patient access sits under more federal rules than any other part of the revenue cycle, because it is where the patient meets the provider. These are the ones that decide what a registrar may ask, must give, and may collect.

Federal · EMTALA

42 USC 1395dd; 42 CFR 489.24

Any patient who comes to a hospital emergency department must receive a medical screening examination and, if an emergency condition exists, stabilizing treatment or an appropriate transfer, regardless of ability to pay. Section 489.24(d)(4) forbids delaying the screening or treatment to inquire about insurance or payment, and forbids seeking prior authorization until screening is complete and stabilization has begun. Reasonable registration that does not delay care is permitted. Violations can end the hospital's Medicare agreement and bring civil monetary penalties.

Federal · No Surprises Act

Public Health Service Act 2799B-6 and 2799B-7; 45 CFR 149.610 and 149.620

Good faith estimates for uninsured and self-pay patients within 1 or 3 business days of scheduling (or on request), and the patient-provider dispute resolution process when a bill exceeds the estimate by $400 or more, started within 120 calendar days. Balance-billing protections for emergency services and for out-of-network care at in-network facilities limit what access may collect to the in-network cost sharing. The insured-patient GFE and advanced EOB await rulemaking; co-provider elements remain under enforcement discretion as of 2026.

Federal · Hospital price transparency

45 CFR Part 180; CY 2026 OPPS final rule (CMS-1834-FC)

Machine-readable standard charge files and a shoppable-services display or estimator. From January 1, 2026 (enforced from April 1, 2026): median, 10th and 90th percentile allowed amounts with counts, derived from remittance data; an accuracy and completeness attestation naming a senior official; Type 2 NPIs in the file. Penalties of $300 per day (30 or fewer beds) or $10 per bed per day up to $5,500 per day, with a 35% reduction for waiving the ALJ hearing. A February 2025 executive order directed stronger enforcement; 519 warning letters went out between April and early June 2026.

Federal · Transparency in Coverage

45 CFR 147.211; 26 CFR 54.9815-2715A; 29 CFR 2590.715-2715A

Non-grandfathered group and individual plans must post in-network negotiated rates and out-of-network allowed amounts (enforced since July 1, 2022) and provide a self-service cost estimator covering 500 items from plan years beginning in 2023 and all items from 2024. The prescription drug file remains under enforcement discretion. Access teams should expect patients to arrive with the plan's estimate and be able to reconcile it.

Federal · Medicare Secondary Payer

42 USC 1395y(b); 42 CFR Part 411; MSP Manual chapter 3

Medicare is secondary to group health plans of employers with 20 or more employees (working aged), large group health plans of 100 or more (disability), any group health plan during the 30-month ESRD coordination period, and to workers' compensation, no-fault, liability and Black Lung benefits. Providers must ask the MSP questions at every admission, encounter or start of care, re-verify every 90 days for recurring outpatients, and keep the answers 10 years. Billing Medicare primary when it is secondary is an overpayment subject to the 60-day return rule.

Federal · Medicare beneficiary notices

Social Security Act 1879 and 1866(a)(1)(Y); 42 CFR 405.1200–405.1206, 489.20(y); Claims Processing Manual chapter 30

Limitation on liability: a beneficiary is not liable for a service Medicare denies as not reasonable and necessary unless given a valid advance notice (ABN, CMS-R-131, revised 2026). The NOTICE Act requires the MOON within 36 hours of observation services for patients observed more than 24 hours. The IM is due within 2 days of admission and again within 2 days of discharge; the NOMNC at least 2 days before covered post-acute services end. Routine or blanket notices are not acceptable; notices are never required in emergencies.

Federal · QMB billing prohibition

Social Security Act 1902(n)(3)(B), 1905(p)(3), 1866(a)(1)(A)

Providers may not bill Qualified Medicare Beneficiaries for Medicare deductibles, coinsurance or copayments, must bill the state Medicaid program instead, and must refund any amounts collected and recall accounts sent to collections. QMB status appears in HETS eligibility responses and on the Medicare remittance. Violations breach the Medicare provider agreement and can bring sanctions.

Federal · HIPAA privacy and Patient Self-Determination Act

45 CFR 164.520, 164.530; 42 CFR 489.102

The notice of privacy practices must be given at the first service with a good-faith effort to obtain written acknowledgment, kept six years. Minimum-necessary rules apply to every eligibility inquiry and every conversation at the desk. Medicare providers must ask about advance directives and document the answer. Section 1557 of the ACA requires language assistance and accessible communication for patients with limited English proficiency or disabilities.

Federal · Section 501(r)

26 USC 501(r); 26 CFR 1.501(r)-1 to -7

Tax-exempt hospitals must maintain a written financial assistance policy and plain-language summary, limit charges to eligible patients to amounts generally billed, make reasonable efforts to determine eligibility before any extraordinary collection action, and wait at least 120 days after the first post-discharge statement. Deferring or denying care because of unpaid bills is an ECA. The policy applies at the point of service, not only in the business office.

Federal · Medicaid changes in the 2025 reconciliation law

Public Law 119-21, sections 71107, 71112, 71119, 71120

Expansion adults face work or community engagement requirements of 80 hours a month, effective no later than December 31, 2026 (states may be exempted until December 31, 2028), eligibility redeterminations every six months for renewals from December 31, 2026, retroactive coverage reduced to one month (two for other groups) from January 1, 2027, and cost sharing of up to $35 per service for incomes of 100 to 138% FPL from October 1, 2028. CBO projects about 10 million more uninsured people by 2034. Financial counseling volume will rise.

Federal · Interoperability (CMS-0057-F) and HIPAA transactions

45 CFR Part 162; CMS-0057-F

Payers must support the 270/271 eligibility and 278 authorization transactions and, from January 1, 2027, Patient Access, Provider Access, Payer-to-Payer and Prior Authorization FHIR APIs for Medicare Advantage, Medicaid, CHIP and federal-exchange plans. Coverage and claims data will increasingly be available inside the EHR at registration.

State law and accreditation

Hospital billing, estimate and collection statutes; Joint Commission NPSG.01.01.01

Many states add estimate rights for insured patients, interest and collection limits on medical debt, facility-fee disclosure, charity-care minimums and presumptive eligibility rules. Payment card handling is governed by the PCI Data Security Standard. Accreditation requires two patient identifiers before every service and documented processes for duplicate and overlay prevention.

Chapter 12

Key numbers 2026–27

Item	Figure	Context
Good faith estimates and disputes
GFE due, service scheduled 3+ business days ahead	1 business day	From scheduling; 45 CFR 149.610
GFE due, scheduled 10+ business days ahead or on request	3 business days	Uninsured and self-pay patients
Dispute threshold	$400	Bill at least $400 above the GFE from that provider or facility
Time to start a dispute	120 calendar days	From the bill; $25 administrative fee
Medicare notices
ABN, revised CMS-R-131	May 12, 2026	Mandatory use; OMB approval March 13, 2026; expires March 31, 2029
ABN estimate accuracy	$100 or 25%	Whichever is greater; retain 5 years
MOON delivery	36 hours	After observation begins, for stays over 24 hours; updated form mandatory April 20, 2026
IM delivery	2 days / 2 days	Within 2 calendar days of admission; copy within 2 days of discharge
NOMNC delivery	2 days	At least 2 calendar days before covered SNF, home health or hospice services end
Medicare Secondary Payer
Working aged employer threshold	20 employees	Current employment; retiree and COBRA plans leave Medicare primary
Disability employer threshold	100 employees	Large group health plan
ESRD coordination period	30 months	Any group health plan, including retiree and COBRA
MSP re-verification for recurring outpatients	90 days	Retain answers 10 years
Prompt-pay period before conditional payment	120 days	Liability and no-fault claims
Medicare cost sharing 2026
Part A inpatient deductible	$1,736	Per benefit period; $434/day for days 61–90, $868 lifetime reserve days
SNF coinsurance, days 21–100	$217/day	After a qualifying 3-day inpatient stay
Part B deductible / standard premium	$283 / $202.90	Annual deductible; monthly premium
Patient cost burden (KFF 2025 employer survey)
Average single deductible	$1,886	Among the 88% of covered workers with a deductible
Deductible of $2,000 or more	34%	Of covered workers, single coverage
Enrolled in HDHP with savings option	33%	Family premium $26,993; worker share $6,850
Denials, estimates and collections
Providers citing missing or inaccurate data as a top denial cause	50%	Experian State of Claims 2025; 32% cite flawed registration data
Patients who received a cost estimate	45%	Experian State of Patient Access 2026; 41% in 2025
Final bill "much more" than the estimate	26%	Down from 44% in 2025
Point-of-service collection rate	24.8%	Kodiak Solutions, hospitals, Q1 2026 (up from 22.7%); POS share of patient payments about 30%
Pre-service share of self-pay collections	21%	HFMA/PayZen 2026; 16% in 2025
Price transparency
Daily penalty	$300 to $5,500	$300 (30 or fewer beds); $10 per bed above 30
Warning letters, April to early June 2026	519	28 hospitals fined since 2021; largest fine $979,000
New allowed-amount elements enforced	April 1, 2026	Median, 10th and 90th percentile from 835 data
Medicaid and coverage 2026–28
2026 federal poverty level, one person	$15,960	Plus $5,680 per additional person; 138% = $22,025
Medicaid work requirements	Dec 31, 2026	80 hours a month; states may be exempted to Dec 31, 2028
Expansion-adult redeterminations	Every 6 months	Renewals from December 31, 2026
Retroactive Medicaid coverage	1 / 2 months	Expansion adults / others, from January 1, 2027 (90 days today)
Marketplace effectuated enrollment, Feb 2026	19.2 million	21.8 million in 2025, after enhanced subsidies expired
Electronic eligibility transactions	96%	CAQH Index 2024; $2.00 electronic vs $8.57 manual per inquiry for providers

What is changing

In effect 2026

New ABN and MOON forms, transparency enforcement

Revised CMS-R-131 mandatory from May 12, 2026 and the updated MOON from April 20, 2026. Hospital price files must carry allowed-amount percentiles and an executive attestation, and CMS is sending warning letters at scale.

Coming Dec 2026 – Jan 2027

Medicaid churn and FHIR APIs

Work requirements, six-month redeterminations and shorter retroactive coverage change financial counseling. CMS-0057-F Provider Access and Payer-to-Payer APIs go live January 1, 2027, bringing coverage data into the EHR.

Unresolved

Insured-patient estimates and the AEOB

The No Surprises Act's advanced EOB and the insured GFE still await rules, and the co-provider GFE element stays under enforcement discretion. Build the insured estimate anyway; patients and state laws expect it.

Sources

Chapter 13

Glossary

Chapter 14

Knowledge check

Eight questions drawn from the chapters above. Pick an answer to see the explanation.

Score: 0 / 8

For training and reference. This page summarizes general rules and does not replace payer contracts, plan documents, CMS manuals, state law or legal advice. Example names, IDs, benefit amounts and payers are fictional.

Figures checked October 15, 2026.