Arista Admissions Screener

1. Client + Payer Details

MRI

Client Name

Admission Rep (free text)

Payer

Plan

Prior Realization % 0.85 = 85%

Estimated LOS Days

Estimated Daily Allowed

Coinsurance Rate 0.25 = 25%

Deductible Total

Deductible Met

Copay Per Day

OOP Max

OOP Met

Lifetime Revenue

Lifetime Patient Responsibility

Lifetime Patient Paid

Lifetime Insurance Paid

Final Decision (required)

Approved By (required)

Approval Date

Force Minimum Upfront optional override

Force Payment Plan Amount optional override

Admissions Notes