CRMC Financial Charity Policy & Application Procedure

1. At any time, during an initial financial screening and continuing collections process, and prior to turnover to Bad Debt, patients who claim to lack the ability to pay will be offered a Financial Assessment Application.
2. The Financial Assessment Application process will be explained by a hospital representative by contacting the Patient Financial Services Department at (256) 737-2986.
3. Patients will be expected to complete the Financial Assessment Application and comply with requirements outlines in the application for supporting documents.

1. The application must be complete in its entirety. – click here to fill out and application online – link to form.
• Within 10 days of receipt, the patient must return the application & supporting documents.
• Additional time may be granted in extenuating circumstances.
2. Supporting documentation includes, but is not limited to: - click here for a printable copy of this list –link to PDF
• Most recent year’s income tax return.
• Copy of social security cards or formal identification for all household members considered in income guidelines.
• Most recent month’s checking and savings statement
• All monthly payment obligations reported on application
• Proof of income in the form of check stubs or a notarized memo from employer; the employer name, address and telephone must be shown on proof of income
• Notarized verification of any support received from friends, family, churches, charitable organizations, etc.
• Written verification of a pending disability case

Exclusions to Supporting Documentation Requirements

1. Administrative Determination
• CRMC Administration may, on a case-by-case basis, and not with prior determination, exempt a patient from requested documentation in the event of extenuating circumstances.
• Details of extenuating circumstances will be documented in the Financial Counselor’s summary and recommendations.
2. Medicaid Recipients
• Patients who exceed their allowed Medicaid inpatient days, indicated on the Medicaid Remittance Advice, will receive a 100% adjustment to the specified account balance. The adjustment code will reflect “Medicaid Exhausted” and will allocate charges to the appropriate charity General Ledger number.
• Business Office will confirm that the recipient ID was correct on the claim filed to Medicaid.
• In the case of recipients under age 21, Business Office will confirm there is no EPST Referral that should have been used on the claim.
3. Good Samaritan Health Clinic Patients
• Those with a qualifying Good Samaritan Health Clinic Patient Identification Card in effect for the date of service Financial Assistance is requested, will not be required to complete the Financial Assessment Application.
• Supporting documentation will be kept by the Good Samaritan Health Clinic.

Eligibility Criteria for Financial Assistance & Discounted Care

• Federal Poverty Levels will be used to determine whether care will be Free or Discounted – see below.
• Households, based upon size of confirmed dependents, not exceeding annual income in the 0% column will receive free care.
• Households, based upon size of confirmed dependents, exceeding annual income in the 0 % column will be asked to pay a percentage of their care. The amount asked will be based upon where the “Household” falls on the grid and actual reimbursement from Medicare. Medicare reimbursement, not gross charges, will be used to calculate the percentage of bill patient will owe.

Charity Review and Assessment

1. Financial Counselors will review Financial Assessment Application with supporting documents, obtain a consumer credit report, summarize the information and recommend approval or denial.
• Patients with credit available at a bank, credit card or other means may be asked for a deposit equal to no more than ½ of credit line.
• Debt to income ratio will be calculated as net income divided by bills. If more than or equal to 2:1, patient may be reassessed for payment options.
• Patient’s annual household income will be compared to eligibility guidelines based upon 150% of Federal Poverty Levels.
2. Recommendations will be assessed by Patient Financial Services Manager, Patient Financial Services Director and/or Chief Financial Officer.
3. Financial Counselor will notify patient of assessment outcome and explain any payment required.

Links for Documents Listed Above:

• Financial Assistance Application
• Printable Supporting Documentation List