Explanation of Pre-Admission
Assignment of Benefits – Authorizes the Insurance Company to reimburse Northside Hospital directly. This also states the patient is not relieved of any responsibility in paying charges not covered by insurance, medical care and treatment. Accounts more than 30 days past due will accrue interest at the rate of 8 percent a year. This interest does not apply to deductibles/co-payments of specifically Medicare/Medicaid or other governmental programs. (Accounts under an agreed alternate payment contract will not be considered past due, provided the plan is accepted in writing in accordance with Northside Hospital’s Payment Installment Agreement Plan within ninety (90) days of service with all conditions of the payment plan met.) This also applies to any newborn child.
Pre-Certification Form – If your insurance company requires pre-certification, it is the responsibility of the patient, guarantor, or the patient’s physician to notify the insurance company.
About Your Billing – In addition to the bill that you receive from Northside Hospital, you may also receive a bill directly from the physician for professional services rendered. The professional services listed below are not performed by Northside Hospital. Specific inquiries regarding professional billing for these services should be directed to the following offices:
Atlanta and Forsyth
Northside Radiology Associates, P.C.
|
(770) 779-2175 |
| Northside Anesthesia (Sentinel) |
(770) 645-7889 |
| Pathology & Lab Medicine (PALM) |
(770) 458-6103 |
| Neonatology |
(404) 252-9751 |
| Atlanta Psychiatric Clinic |
(404) 285-9722 |
| Emergency Department Physician Services |
(770) 779-0015 |
| Physician Billing (GE) |
(800) 770-6805 |
Cherokee
Northside Radiology Associates, P.C. |
(770) 779-2175 |
| Northside-Cherokee Anesthsia Associates |
(770) 237-1286 |
| Tri-County Pathology |
(800) 238-0097 |
| Cherokee Emergency Services, LLC |
(800) 877-7564 |
| Physician Billing (GE) |
(800) 770-6805 |
Private Room Request – The patient understands that private rooms are subject to availability. Insurance companies generally do not pay for the difference in cost between semi-private rooms and private rooms. Therefore, you will pay for the private room differential upon discharge.
Additional Forms required of UNINSURED patients:
Self-Pay Forms – The patient understands that he/she is financially responsible for his/her hospital visit. Accounts more than 30 days past due will accrue interest at the rate of 8 percent a year. This interest does not apply to deductibles/co-payments of specifically Medicare/Medicaid or other governmental programs. (Accounts under an agreed alternate payment contract will not be considered past due, provided the plan is accepted in writing in accordance with Northside Hospital’s Payment Installment Agreement Plan within ninety (90) days of service with all conditions of the payment plan met.) The patient does not have coverage under the Medicaid program, or has applied for Medicaid coverage and has not yet received a determination or eligibility.
COBRA Coverage - If patient has been employed at current job three (3) months or less, or the patient says their coverage is COBRA, initial and complete this information providing Northside Hospital with the necessary information regarding the employer through which the insurance was issued.
Room Assignments and Payment of Room Differences
Every attempt is made to assign you to the specific type of room accommodation you desire. However, that is not always possible, and you may be assigned to a room of other than the type you desire. You may request a semi-private room, but if you are assigned a private room, you will be charged for the room you selected.
If you request and are assigned to a private room, then you will be charged for the difference in room rate between private and semi-private rooms, for each day that you are in the private room. Payment for this differential must be paid when you are discharged.
Infants are charged a daily rate for equipment use, nursing care and treatment. If your insurance coverage does not provide for these charges, then you will be responsible for payment of these charges.
Discharge Procedures
Normal check-out time is 11:00 a.m. You must be prepared to leave your room by that time to avoid additional charges.
Prior to being issued a discharge slip, you may be asked to visit the hospital financial counselors for a final review of your bill. If all financial requirements have been met, then you will be granted a courtesy discharge and excused from the final interview. You will be advised if all financial requirements have or have not been met when you visit the cashier at check out.
Patients will be required to pay all applicable copay, coinsurance and deductible amounts at the time of Pre-Registration for scheduled tests and/or procedures prior to services being rendered. We accept credit cards, checks and cash.
Insurance Billing Policies and Financial Requirements
Most insurance plans require that patients seek authorization from their insurance companies before admission to a hospital. Many plans impose heavy financial penalties, in the form of reduced benefits, on those who fail to comply. It is your responsibility to determine if your plan calls for pre-certification or prior approval and take the steps necessary to satisfy the requirement.
Although Northside Hospital may be a provider in your insurance network, your physician may or may not be a participating provider. This may affect your coverage level for professional services. Please contact your insurance company to learn about your specific coverage.
If you have adequate proof of coverage (an insurance card, for example), have satisfied all prior approval and pre-certification requirements, and provide the appropriate claim forms and completed employee claim statements, then the hospital will accept an assignment of benefits up to the full extent of the coverage available. You must present your insurance card at admission, or the account will be considered self-pay.
Private Pay (Non-Insured) Patients
If you are not covered by insurance, then you need to pay a cash deposit before being admitted to the hospital. The hospital financial counselor will tell you the amount to be paid. Before admission, please call the financial counselor's office, so that you know how much your cash deposit is. Call (404) 851-8878 or (404) 851-8694.
Georgia Law requires that we notify you:
The physicians, physician assistants and nurse anesthetists at Northside Hospital are not employees or agents of Northside Hospital. They are independent contractors engaged in the private practice of medicine who have been granted the privilege of using its facilities. The Hospital does not control the diagnosis and treatment of patients, or the exercise of medical judgment, by these individuals.
Labor and Delivery Patient Consent Form
All labor and delivery patients must sign a Consent Form prior to admission. Please print this document, review it, and sign and initial where indicated. Then, please fax or mail the form, along with copies of both sides of your insurance card, to:
Northside Hospital Pre-Registration Department
1000 Johnson Ferry Road N.E.
Atlanta, Georgia, 30342
FAX: (404) 300-2333
To avoid confusion, please specify "Pre-registration" when forwarding.
At Northside, we respect your privacy. For your protection, all information submitted online is encrypted while in transit. We will not use your information for any other purposes other than admission.
