Attachment 116 -- MPC Pharmacy Instructions & Customer List - Phone Version

Confidential Customer Check List

Page X of Y

[FILL PROVIDER ID]

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 customer(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.

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

Date filled NDC Quantity dispensed

Medicine name Payments and who made them (private insurance, Medicare, Medicaid, out-of-pocket, etc.)

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

Page X of Y

[FILL PROVIDER ID]

PROVIDER NAME:

Confidential Customer 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 customer record in your files. If you choose to mail or fax the medical billing information for each customer, 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 CUSTOMER:
Customer Name	Date of Birth	Gender	2009 Customer Records Located	Found Customer, No 2009 Records	Is Not A Customer
1.  [FILL NAME]	[FILL DOB]	[FILL M or F]			
2.  [FILL NAME]	[FILL DOB]	[FILL M or F]			