Trinity Health Charity, Indigent Care, Uninsured, and Underinsured Guideline (Trinity Cares Financial Assistance Program) GUIDELINE & PROCEDURE

Transcription

1 DEPARTMENT: SUBJECT: Revenue Cycle Trinity Health Charity, Indigent Care, Uninsured, and Underinsured Guideline (Trinity Cares Financial Assistance Prgram) GUIDELINE & PROCEDURE POLICY SUMMARY: Trinity Health is cmmitted t prviding medically necessary health care t all patients. The TrinityCares Financial Assistance Prgram establishes prcedures fr identificatin f participants, determinatin f eligibility and t ffer/prvide financial assistance t all qualified patients fr their health care services. Trinity Health facilities cvered under this guideline include(s) Trinity Hspital, Trinity-St Jseph s Hspital and Trinity Medical Grup prviders. SCOPE: Trinity Health will ffer financial assistance prgrams t all patients wh are a legal resident f The United States f America and are living within ur service area, withut regard t race, creed, sex, natinal rigin, disability, age, r ability t pay, wh present fr care at Trinity Health. PURPOSE: This prgram is designed t prvide financial assistance that can reduce a qualified patient s financial bligatins fr payment f emergency and medically necessary care received at Trinity Hspital, Trinity-St. Jseph s Hspital and Trinity Medical Grup. POLICY: 1. A patient qualifying fr financial assistance is a persn wh is uninsured r underinsured and receives care frm Trinity Health, having made required effrts t pursue ptential third party eligibility cverage and has been verified t be ineligible fr any ther frm f financial care payment cverage. 2. T be eligible fr assistance under the financial assistance guidelines, a persn s husehld incme shall be belw 250% f Federal Pverty Incme Guidelines. Trinity Health will cnsider ther financial assets and liabilities f the persn, when determining eligibility. 3. Trinity Health will use the mst current pverty incme guidelines issued by the U.S. Department f Health and Human Services t determine an individual s eligibility fr financial assistance. The pverty incme guidelines are published in the Federal Register and fr the purpses f this plicy will becme effective the first day f the mnth fllwing the mnth f publicatin. Trinity Health TrinityCares Financial Assistance Guideline & Prcedure Page 1

2 Definitins: Fr the purpse f this plicy, the fllwing definitins apply: Emergency Care and Services: As defined in Sectin 1867 f the Scial Security Act (42 U.S.C. 1395dd) is a medical cnditin manifesting itself by acute symptms f sufficient severity (including severe pain) such that the absence f immediate medical attentin culd reasnably be expected t result in : (1) placing the health f the individual (r, with respect t a pregnant wman, the health f the wman r her unbrn child) in serius jepardy, (2) serius impairment t bdily functins, r (3) serius dysfunctin f any bdily rgan r part.) Emergency Medical Treatment and Active Labr Act (EMTALA): An act f the United States Cngress passed in It requires hspital Emergency Departments that accepts payments frm Medicare t prvide an apprpriate medical screening examinatin (MSE) t individuals seeking treatment fr a medical cnditin. Participating hspitals may nt transfer r discharge patients needing emergency treatment except with the infrmed cnsent r stabilizatin f the patient r when their cnditin requires transfer t a hspital better equipped t administer the treatment. Medical Necessity: Medically Necessary r Medical Necessity shall be defined as any necessary health care services that a physician r ther healthcare prvider, exercising prudent clinical judgment wuld prvide t a patient, fr the purpse f preventing, diagnsing, evaluating, r treating a significant illness, injury r disease which causes: Acute suffering Endangers life Threatens significant patient harm, injury r negative health utcme Medically necessary services are nt primarily fr the cnvenience f the patient, physician, r ther health care prvider, and nt mre cstly than an alternative service r sequence f services at least as likely t prduce equivalent therapeutic r diagnstic results as t the diagnsis r treatment f that patient s significant illness, injury r disease. Extrardinary Cllectin Actins (ECA s): Especially aggressive effrts t encurage individuals t pay a liability, as defined in Reg (r)-6(b). In general, extrardinary cllectin actins include, selling a debt t anther party, reprting adverse infrmatin abut an individual t a cnsumer credit reprting agency r credit bureau; deferring r denying medically necessary care because f nnpayment f a previus liability; requiring payment befre prviding medically necessary care because f nnpayment f a previus liability; and actins that require a legal r judicial prcess (including liens, freclsures, attachments, seizures, civil actins, arrests, writs f bdy attachment, and garnishments). Husehld Incme: Incme f any wrking adult, living within husehld n matter relatinship, hwever, will nt include any wrking teenager, r wrking cllege student under the age f 26. Trinity Health TrinityCares Financial Assistance Guideline & Prcedure Page 2

3 Amunts Generally Billed ( AGB ) Limit: The average amunt cllected by Trinity Health fr prviding emergency and ther medically necessary health care services t individuals wh have insurance cvering that service, as defined in Reg (r)-1(b)(1). Service Area: Service Area: Trinity Health s service area includes Nrthwestern Nrth Dakta and Nrtheastern Mntana. Please refer t the shaded area in the map belw fr the cunties included in this service area: PROCEDURE: 1. T qualify fr the TrinityCares Prgram, the fllwing must be met: a. A rati is develped by dividing the individual s incme by the Federal Pverty Guidelines Pverty Guidelines fr 48 Cntiguus States and the District f Clumbia Persns in Family Pverty Guideline 250% Of the Federal Pverty Guideline 1 $11,880 $29,700 2 $16,020 $40,050 3 $20,160 $50,400 4 $24,300 $60,750 5 $28,440 $71,100 6 $32,580 $81,450 7 $36,730 $91,825 8 $40,890 $102,225 a. The rati is matched t the fllwing chart, t determine amunt eligible fr financial assistance. Rati Assistance Percentage 0% - 250% 100% 251%-Over 0% Trinity Health TrinityCares Financial Assistance Guideline & Prcedure Page 3

4 b. The fllwing factrs will be cnsidered in determining the eligibility fr financial assistance: a. Prf f Incme (t include ne r mre f the fllwing :) i. Adjusted Grss Incme if self-emplyed and all schedules frm the mst current tax frm ii. Listing f Assets and Investments iii. Emplyment status and future earning capacity b. Number f Dependents c. Other financial bligatins 2. Services Eligible under this Plicy a. Fr purpses f this plicy, Trinity Health reserves the right t determine, n a case-by-case-basis, whether the care and services meet the definitin medically necessary ; fr the purpse f eligibility fr financial assistance. Emergent prcedures will be cnsidered Medically Necessary. All nn-emergent care and elective care will be subject t review. Medical necessity will be reviewed by Trinity Health Case Management Department, Business Office, Physician, r ther Healthcare Prvider. The Medical Directr f Value Initiatives r designee and CFO will make the final decisin n medical necessity after cnsulting with the abve departments. b. Sme examples f nn-medically necessary services: i. Dietary cunseling ii. Circumcisin iii. Exercise Physilgy (i.e. sprts kinetics, etc) iv. Infertility wrk-ups and injectins v. Csmetic surgery (i.e. Radial kerattmy, Blepharplasty, Lipsuctin, Lasik Eye Surgery, etc.) vi. Sterilizatin prcedures vii. Retail Services (i.e. ptical shp, pharmacy, and hearing assistive devices) viii. Rutine and Preventative Office visits ix. Nn-emergency dental services x. Durable Medical Equipment xi. Experimental Treatments xii. Services cnsidered nn-cvered by mst carriers xiii. Rutine Eye Exams xiv. Hme Health/Hspice xv. Grund ambulance that is nt t r frm Trinity Health xvi. Nte: This listing may nt be inclusive c. See Attachment A fr a list f prviders wh perate within Hspital. Attachment A identifies thse prviders wh services are nt eligible fr Trinity Health TrinityCares Financial Assistance Guideline & Prcedure Page 4

5 3. Eligibility Criteria TRINITY HEALTH charity care under this plicy. Attachment A shall be updated at least quarterly t maintain accuracy. A. Residency: Resident shall mean a persn wh is a legal resident f the United States and wh has been a legal resident f the service area (which includes Nrthwestern Nrth Dakta and Nrtheastern Mntana), in which medical services are sught fr at least six mnths at the time services are prvided and has the intent t remain in the state in which medical services are sught fr at least six mnths after services are prvided. B. Every applicant must prvide tw (2) frms f valid identificatin; ne must be a pht ID. Acceptable frms f identificatin are the fllwing: State issued ID/Driver s License/ Military ID Alien registratin/green Card/Permanent resident card Gvernment issued pht ID Birth Certificate Scial Security Card Passprt Certificate f Citizenship Official dcument that includes name, address, scial security number C. Dcumentatin prvided as prf f residency must have applicant s full name and physical address. At least tw f the fllwing items must be prvided: Current Utility Bill Current Hmewners/Aut Insurance Plicy r Bill Prperty Tax Bill Rental/Lease/Mrtgage Agreement Vters Registratin Card Vehicle Registratin Official mail received at hme f residency within 60 days Prf f children enrlled in Schl District D. Other Medical Cverage: Charity care is generally secndary t all ther financial resurces available t the patient, including grup r individual medical plans, wrkers cmpensatin, Medicare, Medicaid r medical assistance prgrams, ther state, federal r military prgrams, r any ther situatin in which anther persn r entity may have a legal r financial respnsibility t pay fr the cst f medical services. E. Annual Grss Husehld Incme/Assets: In thse situatins where apprpriate primary payment surces are nt available, patient shall be cnsidered fr charity care under this plicy. All resurces f the husehld are cnsidered in determining the applicability f the financial assistance apprval. These resurces include bank accunts, investment accunts, retirement accunts, ther securable assets Trinity Health TrinityCares Financial Assistance Guideline & Prcedure Page 5

6 (recreatinal vehicles, campers, livestck, etc.) and real estate excluding the primary residence (rental prperties, vacatin hme, etc.) F. Prcess fr Applicatin A. An individual is nt eligible fr financial assistance if they have cuntable assets (i.e. saving accunts, checking accunts, stcks, bnds, r similar assets) greater than $3000. The limit is $6000 per husehld. B. An individual is nt eligible fr financial assistance if their husehld s cmbined Adjusted Grss Incme (AGI) greater than 250% f Federal Pverty Guidelines (FPG). C. An individual with AGI and cuntable assets belw these threshlds qualifies fr 100% financial assistance. A. Trinity Health shall use an applicatin fr determining eligibility fr TrinityCares. Hwever, Trinity Health may presumptively determine an individual s eligibility fr charity care under this plicy withut a cmpleted applicatin based n infrmatin in sectin D (b) f this plicy. B. When submitted fr cnsideratin, a TrinityCares applicatin shall be accmpanied by the fllwing dcumentatin if applicable: i. Cmpleted and Signed Financial Assistance applicatin ii. Apprval/Denial Letter frm Medicaid if applicable iii. Cpy f mst recent Federal Tax Return (Frm 1040 r equivalent), including all schedules iv. Tw mnths f cmplete bank statements fr checking and saving accunts fr all husehld members v. Verificatin f current incme, if applicable: examples include the tw mst recent pay stubs, pensin and retirement benefits, Scial Security benefits, unemplyment cmpensatin, Wrkers Cmpensatin, Veteran s benefits, etc. vi. Prf f incme frm dividends, interest, rents, ryalties, annuity payments, estates, trusts, inheritance prceeds and student aid nt subject t repayment vii. Gifts: t include dnatins frm churches, family members and ther rganizatins In the event that the respnsible party is nt able t prvide any f the dcumentatin prvided abve, Trinity Health shall rely upn written and signed statements frm the respnsible party fr making a final determinatin f eligibility f charity care. C. Cmpleted applicatins and dcumentatin shuld be submitted t the Patient Financial Services Business Office. Acceptable methds f submissin include: a. Mail t: PO Bx 5020, Mint ND Attn: Patient Financial Services Trinity Health TrinityCares Financial Assistance Guideline & Prcedure Page 6

7 b. Deliver in Persn t: Trinity Health Business Services, 1015 S. Bradway Ste. 301Mint, ND c. Fax t: , Attn: Patient Financial Services D. Failure t Prvide Apprpriate Infrmatin If a respnsible party submits an incmplete Financial Assistance Applicatin, Trinity Health shall take the fllwing steps t encurage them t cmplete the applicatin: a. The Business Office will send the patient a letter asking fr additinal dcumentatin when needed. The additinal dcumentatin shuld be returned t the Business Office within 14 days frm the date f the letter. Failure t prvide necessary infrmatin t cmplete a financial assessment may result in a negative determinatin, but the accunt may be recnsidered upn receipt f the required dcumentatin. b. The accunt may als be submitted fr apprval if Trinity Health has been able t verify incme infrmatin frm a reliable third party, i.e. Scial Security, Medicaid, etc. c. A determinatin f eligibility fr financial assistance may be made withut a cmpleted assessment frm, by the Revenue Cycle Supprt Services Directr, if the patient r infrmatin is nt reasnably available and eligibility is warranted under the circumstances. E. Peridic Audits a. Revenue Cycle Supprt Services Directr, Vice President f Revenue Cycle, and Chief Financial Officer will review a sample f all accunts mnthly t assure that patient accunt write ff plicies are being fllwed and that prper dcumentatin is present. Required levels f mnthly review, are as fllws: i. Revenue Cycle Supprt Services Directr: Review f all accunts ii. Revenue Cycle Vice President: Review all accunts with balances $25,000 and greater iii. Chief Financial Officer: Review all accunts with balances $50,000 and greater F. Dcumentatin f Eligibility Determinatin a. While a Financial Assistance Applicatin is pending final eligibility determinatin, Trinity Health will nt initiate cllectin effrts r requests fr depsits prvided nce the respnsible party is cperative with Trinity Health s effrts t reach a determinatin, which includes the respnsible party returning the applicatin and supprting dcumentatin within 14 days f receiving the applicatin. b. Fllwing the initial request fr financial assistance, Trinity Health may pursue ther surces f funding, including Medicaid, Indian Health Services, State Hspital Assistance Prgram, etc. Hspital may delay Trinity Health TrinityCares Financial Assistance Guideline & Prcedure Page 7

8 prcessing a financial assistance applicatin until after the individual s Medicaid eligibility has been determined. c. All infrmatin relating t the applicatin will be kept cnfidential. Cpies f dcuments that supprt the applicatin will be kept with the applicatin frm. d. Once an eligibility determinatin has been made, Trinity Health will ntify the respnsible party within 14 days f receipt f a cmpleted charity care applicatin and all necessary supprting dcumentatin. The results f the determinatin will be nted in the cmments sectins f the billing recrd. The patient will receive a letter frm the Business Office stating the eligibility determinatin. e. The financial assistance apprval can be extended up t a maximum f six mnths frm the apprval date t cver future qualified care r services and will cnsider balances n services which ccurred within the last 240 days nly. T be eligible fr this extended term Trinity Health may require patients r guarantrs t prvide updated financial infrmatin. f. If Trinity Health denies an individual s applicatin fr financial assistance, Trinity Health will ntify the individual in writing f the denial and the basis fr the denial. g. If the financial situatin changes it is the respnsibility f the patient t ntify the Trinity Health Business Office. Trinity Health reserves the right t request additinal dcumentatin if the financial situatin has changed and t reassess the financial assistance apprval at any time during the apprval timeframe. h. The Revenue Cycle Supprt Directr will keep n file, all apprved accunts fr review by Management r ther third parties. i. Fr thse accunts disallwed fr financial assistance, the patient will be ntified in writing and further cllectin effrts will be cnsidered accrding t pre-established Business Services Prcedures. G. Prcess fr Amunts Generally Billed a. Any individual wh is determined t be eligible fr financial assistance under this plicy shall nt be required t pay mre fr emergency medical care and ther apprpriate medical services than the amunts generally billed t individuals wh have health insurance cvering such care. b. This AGB limit shall be used by Trinity t determine the maximum amunt that an individual may be liable t pay after such individual is determined t be eligible fr financial assistance under this plicy. c. Trinity Health shall use the Prspective Methd as described in Regulatin 1.501(r)(5) d. Attachment B cntains infrmatin abut the currently applicable AGB limit and hw it was calculated. Trinity Health TrinityCares Financial Assistance Guideline & Prcedure Page 8

9 H. Prcess fr Cmmunicatin a. Patient Financial Services Business Office at Trinity Health shall prvide infrmatin abut its TrinityCares plicy and/r prvide assistance with the Financial Assistance Applicatin prcess. The Patient Supprt Services Department is lcated at: 1015 S. Bradway Ste.301 Mint, ND and is available by phne at: Mnday- Friday 8am-5pm b. Trinity Health will ntify and infrm individuals abut the availability f charity care in the fllwing ways: i. Trinity Health shall set up cnspicuus public displays that ntify and infrm patients abut the financial assistance prgram. Such displays shall be lcated in the emergency rm and all admissins areas. Such displays shall include the fllwing infrmatin: a. Displays will include a statement that Trinity Health ffers financial assistance t eligible individuals b. Infrmatin abut hw r where t btain infrmatin abut the TrinityCares plicy and applicatin prcess c. Infrmatin abut hw r where t btain cpies f this financial assistance plicy, a plain language summary f this financial assistance and the financial assistance applicatin ii. Trinity Health will ffer a paper cpy f the plain language summary f this financial assistance plicy t patients as part f the intake and/r discharge prcess iii. Trinity Health will include the fllwing infrmatin n all billing statements. 1. Financial assistance is available under the TrinityCares plicy. 2. The telephne number f a Trinity Health ffice r department that can prvide infrmatin abut the TrinityCares Plicy and prcess. 3. The direct web site address (URL) n which this TrinityCares Plicy, a plain language summary f this plicy and the Financial Assistance applicatin are available. iv. Paper cpies f this Financial Assistance applicatin, a plain language summary, and the Financial Assistance applicatin shall be made available upn request and withut charge. These paper cpies shall be available by mail, in Trinity Health s emergency rm, and all ther admissins areas t Trinity Health. v. Trinity Health shall take reasnable effrts t ntify and infrm members f the cmmunity abut this financial assistance plicy in a manner that is reasnably calculated t reach thse cmmunity members wh are mst likely t need financial assistance frm Trinity. vi. Trinity Health will make reasnable effrts t help vercme any language r disability barrier that may serve as an impediment t infrming patients and guarantrs abut the availability f financial assistance, including: 1. Multi-lingual signs in English and any ther language that cnstitutes the primary language f at least 5% f the ppulatin in the cmmunity where the facility is lcated. Trinity Health TrinityCares Financial Assistance Guideline & Prcedure Page 9

10 2. Prviding interpreters upn request f the patient r patient cmpanin/care taker t accmmdate either language r disability needs I. Prcess fr Cllectins a. See Attachment C fr a list f actins that may be used by Trinity Health t cllect liabilities frm individuals, including extrardinary cllectin actins. Attachment C als prvides a general timeframe fr these actins b. Trinity Health prhibits the use f all extrardinary cllectin against individuals ther than actins listed in Attachment C. This prhibitin applies t Trinity Health and t all parties acting n behalf f Trinity Health. c. If an individual submits a financial assistance applicatin, Trinity Health shall cease all cllectin effrts until a determinatin f eligibility has been made. d. If Trinity Health r anther authrized party has already begun an extrardinary cllectin actin against an individual when that individual submits a financial assistance applicatin, the ECA shall be suspended. Suspending an actin, means that n new ECA actins are initiated and n further steps are taken n a previusly existing ECA. e. Trinity Health shall nt take any ECA against an individual fr an episde f care within 120 days f the date the first pst-discharge billing statement is sent t the individual. f. At least 30 days prir t taking any ECA against an individual t btain payment fr an episde f care, Trinity Health r its agents shall prvide the individual with a written ntice that includes the fllwing infrmatin. i. Financial assistance is available fr eligible individuals ii. The ECA that Trinity Health r anther authrized third party, intends t initiate against the individual t btain payment fr the care iii. Deadline after which such ECA may be initiated. The written ntice shall include a cpy f the plain language summary f this financial assistance plicy. Trinity Health r anther authrized third party shall als make reasnable effrts t rally ntify the respnsible party abut this financial assistance plicy and hw the individual may btain assistance with the financial assistance prcess. g. The Patient Supprt Services department shall have the final authrity and respnsibility t determine whether Trinity Health has made reasnable effrts t determine whether an individual is eligible fr financial assistance under this plicy and may therefre engage in ECA s against that individual. h. If an individual has made partial payment, and the individual is subsequently determined t qualify fr financial assistance under this plicy, any payments in excess f their newly calculated remaining liability shall be refunded t the patient within 60 days f the financial assistance eligibility determinatin. Trinity Health Bard Apprved Date: June 23, 2016 Trinity Health TrinityCares Financial Assistance Guideline & Prcedure Page 10

11 Attachment A I. Prviders Nt Subject t the Financial Assistance Plicy: Prviders wh maintain privileges at Trinity Hspital, St. Jseph s Hspital, Trinity Health Centers r Trinity Health Cmmunity Clinics lcatins wh are nt emplyed r cntracted by Trinity Health/Trinity Medical Grup are nt subject t this Financial Assistance Plicy and will bill patients directly. Residents and faculty wrking under the University f Nrth Dakta Medical Schl residency prgram r Center fr Family Medicine Residency prgram are nt subject t this agreement and will bill patients directly. Prviders wh may deliver services at the abve lcatins and are nt subject t this Financial Assistance Plicy include: Adum, Vivian MD OB/GYN L, Li Er MD OB/GYN Newtn, Ylanda MD OB/GYN Slberg, Sara R MD OB/GYN Tng, Beverly J MD OB/GYN Slann, Guy DPM Mehta, Rajnikant MD - Physiatrist Behm, Lance DDS Glsenger, Jeremiah DDS Hamiltn, Jhn DDS WD-ASC Hildahl, Mark DDS Hirst, Stanley DDS Smmers, Dennis DDS Steininger, Lawrence DDS Krhn, Kimberly, MD Bahal, Paul MD Schlecht, Kristina MD Devlin, Kwanza MD Stripe, Stephen MD Rickert, Julie PsyD Reviewed By: Renda Wilsn Date: June 24, 2016 Trinity Health TrinityCares Financial Assistance Guideline & Prcedure Page 11

12 Attachment B Trinity Health uses the Prspective Methd as defined in Reg (r)-5(b) t calculate the amunt generally billed (AGB) t individuals wh have insurance cvering medically necessary care. Any individual wh is determined t be eligible fr financial assistance under this plicy shall nt be required t pay mre than the amunts generally billed t individuals wh have insurance cvering such care, 1. Trinity Health will use the Medicaid Fee fr Service n the fllwing Services: Inpatient Rehabilitatin Inpatient Mental Health Hspital Inpatient Chemical Dependency Rural Clinics Nn-Hspital Based 2. Trinity Health will use the Medicare Fee fr Service n the fllwing Services: Radilgy Lab Outpatient Therapy Same Day Surgery Kidney Dialysis Services Ambulance Services- Fixed wing, Rtary Air, Grund t and frm Trinity Health Hspital Observatin Services Emergency Rm Trinity Medical Grup Physician Services Reviewed By: Dennis Empey, CFO Date: June 24, 2016 Trinity Health TrinityCares Financial Assistance Guideline & Prcedure Page 12

13 Attachment C Trinity Health Cllectin Actins 1. This attachment identifies the actins taken by Trinity Health t encurage patients and ther respnsible parties t pay a liability wed t Trinity Health fr the prvisins f apprpriate hspital-based medical care, including extrardinary cllectin actins. It identifies the general timeline used by Trinity Health in taking these actins: Trinity Health sends a billing statement upn determining the remaining balance after any insurance. This initial billing statement is referred t as the first-pst discharge billing statement. This billing statement will infrm the patient f a pssible prmpt pay discunt, payment plan ptins and financial assistance (additinal infrmatin n the prmpt pay discunt is listed within the Billing and Cllectins Plicy) Apprximately 30 days frm the initial billing statement a letter is sent Apprximately 30 days later a secnd letter is sent Apprximately 30 days later a third letter is sent with a ntice f intended actins (final ntice statement). This letter will advise the patient f financial assistance ptins, plain language summary and ntice f pssible placement with cllectin agency. General cllectin activities may include fllw-up calls n statements and letters, including manual and autdialed calls t a hme, wrk, r cell phne. Between 14 and 30 days later, the accunt is sent t an utside cllectin agency While the accunt is with the cllectin agency, the cllectin agency attempts t cntact the individual by phne Within a week f the receipt f accunt, the cllectin agency sends a letter encuraging payment and infrming the individual f actins that may be taken. Apprximately 30 days later the cllectin agency may begin charging interest fees Apprximately 90 days later, the cllectin agency reprts the accunt t a cnsumer credit reprting agency After reprting the accunt t a cnsumer reprting agency, the cllectin agency may cmmence a legal actin against the individual. Trinity Health limits allwable legal actins t garnishment f wages, lawsuits, and liens. 2. If a patient has an utstanding balance fr previusly prvided care, Trinity Health may engage in the ECA f deferring, denying, r requiring payment befre prviding additinal medically necessary (but nn-emergent) care nly when the fllwing steps are taken: a. Trinity Health prvides the patient with an FAP applicatin and a plain language summary f the Financial Assistance Plicy. b. Trinity Health prvides a written ntice indicating the availability f financial assistance and specifying any deadline after which a cmpleted applicatin fr assistance fr the previus care episde will n lnger be accepted. The deadline must be at least 30 days after the final ntice date r 240 days after the first pst-discharge billing statement fr prir care-whichever is later. c. Trinity Health prcessed n an expedited basis any FAP applicatins fr previus care received within the stated deadline. Trinity Health TrinityCares Financial Assistance Guideline & Prcedure Page 13

14 d. Revenue Cycle Supprt Services and Business Office Directrs are ultimately respnsible fr determining whether Trinity Health have made reasnable effrts t determine whether an individual qualifies fr financial assistance and may therefre initiate an ECA. Trinity Health prhibits the use f all extrardinary cllectin actins ther than the actins listed here. This prhibitin applies t Trinity Health and t all ther parties n behalf f Trinity Health. While the timeline abve is generally accurate any step may fluctuate. Hwever, in n event shall Trinity Health r an authrized third party take any extrardinary cllectin actins within 120 days f sending the first pst-discharge billing statement t a respnsible party. Reviewed By: Trent Chastain, VP Date: June 24, 2016 Trinity Health TrinityCares Financial Assistance Guideline & Prcedure Page 14