Attachment 83 -- MPC Home Health Instructions & Client Check List - Phone Version

Confidential Client Check List

[FILL PROVIDER ID]

[FILL PROVIDER NAME:]

Instructions

Thank you for taking the time to provide this medical billing information. We realize your time is valuable and limited. A data collection specialist will be calling you soon to collect this information over the telephone. If you would like to contact us directly, please call [FILL APPROPRIATE 800 NUMBER].

The client(s) listed below have given us written authorization to contact you and request information from your records. Copies of the signed authorization forms are attached.

Please complete the following steps to provide us with the records we need.

Step 1: Please Locate Medical Billing Records for Each Client in Your Records: For each client included in the Confidential Client Checklist, please locate the following information on all services each client received between January 1, 2009 and December 31, 2009:

Date(s) of service Services provided Type of personnel who delivered services Diagnoses/conditions

Payments and who made them (private insurance, Medicare, Medicaid, out-of-pocket, etc.) Charges for each service provided and total charges

Step 2: Please Record Outcome on the Confidential Client Checklist: You can use the Confidential Client Check List as a reference tool to record whether you were able to locate the records for each client on the list. You can indicate whether you were able to locate the 2009 client records, if you were able to locate the client but there were no 2009 records, or if the individual is not a client, by checking the appropriate box next to the client in the Confidential Client Checklist.

Step 3: Please Provide Information to Data Collection Specialist via Telephone: We will be calling you shortly to collect the information. Should you prefer, you can fax or mail the information using the attached Fax or Mail Return Form. If returning records by fax or mail, please include the completed Confidential Client List, with the appropriate box checked for each client, in the package.

Page X of Y

[FILL PROVIDER ID]

PROVIDER NAME:

Confidential Client Check List

If you provide the medical billing information over the telephone, you may use this list as a reference tool for recording the outcome of locating each client record in your files. If you choose to mail or fax the medical billing information for each client, please include this checklist form with your materials.

  REMINDER:  
IF RETURNING RECORDS BY FAX OR MAIL,
PLEASE INCLUDE THIS CHECKLIST FORM.

If faxing material, please fax to: If mailing material, please send to:

[FILL APPROPRIATE RTI-SSS MEPS-Medical Provider Component Director
NUMBER: 1-800-XXX-XXXX] One North Commerce Center

5265 Capital Boulevard

Raleigh, NC 27616

			CHECK ONE FOR EACH CLIENT:
Client Name	Date of Birth	Gender	2009 Client Records Located	Found Client, No 2009 Records	Is Not A Client
1.  [FILL NAME]	[FILL DOB]	[FILL M or F]			
2.  [FILL NAME]	[FILL DOB]	[FILL M or F]			
3.  [FILL NAME]	[FILL DOB]	[FILL M or F]			
4.  [FILL NAME]	[FILL DOB]	[FILL M or F]			
5.  [FILL NAME]	[FILL DOB]	[FILL M or F]			
6.  [FILL NAME]	[FILL DOB]	[FILL M or F]			
7.  [FILL NAME]	[FILL DOB]	[FILL M or F]			
8.  [FILL NAME]	[FILL DOB]	[FILL M or F]			

Page X of Y

			CHECK ONE FOR EACH CLIENT:
Client Name	Date of Birth	Gender	2009 Client Records Located	Found Client, No 2009 Records	Is Not A Client
9.  [FILL NAME]	[FILL DOB]	[FILL M or F]			
10.  [FILL NAME]	[FILL DOB]	[FILL M or F]			
11.  [FILL NAME]	[FILL DOB]	[FILL M or F]			
12.  [FILL NAME]	[FILL DOB]	[FILL M or F]			
13.  [FILL NAME]	[FILL DOB]	[FILL M or F]			
14.  [FILL NAME]	[FILL DOB]	[FILL M or F]			
15.  [FILL NAME]	[FILL DOB]	[FILL M or F]			
16.  [FILL NAME]	[FILL DOB]	[FILL M or F]			
17.  [FILL NAME]	[FILL DOB]	[FILL M or F]			
18.  [FILL NAME]	[FILL DOB]	[FILL M or F]			