Form #1 Form #1 Home Health Contact Guide for Organizations
Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC)
Attachment 68 MPC Hospital Contact Guide
MPC Contact Guide/Screening Call
OMB: 0935-0118
MEDICAL EXPENDITURE PANEL SURVEY (MEPS) - MEDICAL PROVIDER COMPONENT (MPC)
Attachment 68
Contact Guide
FOR
HOSPITAL PROVIDERS
REFERENCE YEAR 2014
[MR_A]CALL PROVIDER:
MR_A1. Hello, have I reached [PROVIDER]?
PHONE NUMBER: [PROVIDER TELEPHONE NUMBER]
YES…………………………………………….........................= 1
NO, BUT CAN RECORD A NEW NUMBER..........................= 2
NO, NEED TO TRACE THE CASE.………............................= 3
[IF MR_A1 = 1 GO TO MR_A2,
IF MR_A1 = 2 GO TO CONTACT BLOCK,
IF MR_A1 = 3 GO TO EXIT SCREEN]
MR_A2. I have [an] authorization form[s] for the release of medical records and would like to speak to the person who can help me with that process.
IF RECORDS ARE KEPT BY A MEDICAL RECORDS SERVICE, ASK TO SPEAK WITH THE PERSON IN THE OFFICE WHO DEALS WITH THE MEDICAL RECORDS SERVICE.
CONTINUE, THIS PERSON CAN HELP = 1
COLLECT CONTACT INFORMATION FOR SOMEONE ELSE = 2
NO MEDICAL RECORDS DEPARTMENT; UNCLEAR WHO HANDLES RECORDS = 3
[IF MR_A2= 1 GO TO MR_B1,
IF MR_A2=2 GO TO CONTACT BLOCK,
IF MR_A2=3 GO TO EXIT SCREEN]
[MR_B]IDENTIFY DC POC
MR_B1. My name is (YOUR NAME). I am calling on behalf of the U.S. Department of Health and Human Services.
We are conducting MEPS which is a study about how people in the United States use and pay for health care.
For quality assurance and training purposes, this call may be monitored.
POC: [POC NAME]
READ IF NECESSARY: I have [an] authorization form[s] for the release of medical records and would like to speak to the person that can help me with that process.
IF THIS PERSON CANNOT HELP, ASK TO BE TRANSFERRED TO SOMEONE WHO CAN.
CONTINUE, THIS PERSON CAN HELP.........................= 1
COLLECT CONTACT INFORMATION FOR SOMEONE ELSE..........................= 2
[IF MR_ B1=1, GO TO MR_B2,
IF MR_B1=2, GO TO CONTACT BLOCK]
MR_B2. Thank you. First, can you confirm that this is a hospital, hospital outpatient department, hospital satellite clinic, surgi-center, or a skilled nursing facility?
YES, THIS IS A HOSPITAL, HOSP OUTPATIENT DEPT, HOSP SATELLITE CLINIC, SURGI-CENTER, OR SKILLED NURSING FACILITY........................................1
NO, THIS IS NOT A HOSPITAL, HOSP OUTPATIENT DEPT, HOSP SATELLITE CLINIC, SURGI-CENTER, OR SKILLED NURSING FACILITY........................................2
[IF MR_B2=1 GO TO MR_B4;
IF MR_B2=2 GO TO MR_B3a.]
MR_B3a. How would you describe this facility? Is this:
A doctor's office.........................................................................................1
A publicly-funded clinic..............................................................................2
An urgent care center................................................................................3
A home care provider................................................................................4
A long term care facility, such as a nursing home, or................................5
Something else (SPECIFY)?.....................................................................6
(READ ONLY IF NECESSARY:
A hospital outpatient department, hospital satellite clinic, surgi-center, or skilled nursing facility?)
IF RESPONDENT REPORTS HOSPITAL OUTPATIENT DEPARTMENT, HOSPITAL SATELLITE CLINIC, SURGI-CENTER, OR SKILLED NURSING FACILITY GO BACK TO
ITEM MR_B2 - ELIGIBILITY– VERIFY HOSPITAL AND CODE ACCORDINGLY.
[IF MR_B3a=1,2,3,4,5 GO TO MR_B4;
MR_B4. At this time, [NUMBER FROM PATIENT LIST] patient[s] identified [PROVIDER] as a source of health care during [FILL_YR]. [The/Each] patient signed an authorization form allowing us to contact you for information about the care
they received from [PROVIDER] in [FILL_YR]. Much of the information we need is within the medical records. Are the medical records maintained in your office, or is a medical records service used?
OFFICE MAINTAINS THE INFORMATION = 1
OFFICE USES A MEDICAL RECORDS SERVICE = 2
[IF MR_B4 = 1 GO TO MR_B4b,
IF MR_B4 = 2 GO TO MR_B4_1]
MR_B4_1. Are you the person who deals with the medical records service?
YES.........................= 1
NO...........................= 2
[If MR_b4_1 = 1, go to MR_C2,
if MR_b4_1 = 2, go to MR_b4a]
MR_B4a. I’ll need to collect the name and telephone number for the person in your office who deals with the medical records service.
MR_B4b. I would like to fax the authorization form[s] to you, along with additional information explaining the study.
I need to be sure I have the correct information for the packet. Should I direct it to you?
READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S): In order to remain HIPAA compliant, I need to send you the authorization form[s] first. Once you have received the form[s], then we can arrange for the collection of the data.
YES.........................= 1
NO...........................= 2
[go to CONTACT block]
MR_B5. Can you please provide the name and number for the person who (needs to receive the courtesy packet/needs
to receive the forms) to approve the release of data?
YES.........................= 1
NO..........................= 2
[IF MR_B5 = 1 GO TO CONTACT BLOCK,
IF MR_B5 = 2 GO TO EXIT SCREEN.]
[MR_C]IDENTIFY MR SERVICE
MR_C1. Hello, my name is (YOUR NAME).
I am calling on behalf of the U.S. Department of Health and Human Services.
We are conducting MEPS which is a study about how people in the United States use and pay for health care.
For quality assurance and training purposes, this call may be monitored.
POC: [POC NAME]
READ IF NECESSARY: I have [an] authorization form[s] for the release of medical records and would like to speak to the person that can help me get in touch with the medical records service that maintains your records.
IF THIS PERSON CANNOT HELP, ASK TO BE TRANSFERRED TO SOMEONE WHO CAN.
CONTINUE, THIS PERSON CAN HELP.........................= 1
COLLECT CONTACT INFORMATION FOR SOMEONE ELSE........................= 2
[IF MR_C1=1, GO TO MR_C2,
IF MR_C1=2, GO TO CONTACT BLOCK]
MR_C2. READ IF NECESSARY: At this time, [NUMBER FROM PATIENT LIST] patient[s] identified [PROVIDER] as a
source of health care during [FILL_YR]. [The/Each] patient signed an authorization form allowing us to contact you for
information about the care they received from [PROVIDER] in [FILL_YR].
We should be able to get all of the information we need from the medical records service.
We can also fax you a copy of the authorization form[s] for your files.
I need to be sure I have the correct information for the packet. Should I direct it to you?
READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S)]: In order to remain HIPAA compliant, I need to send you the authorization form[s] first. Once you have received the form[s], then we can arrange for the collection of the data.
YES.........................= 1
NO...........................= 2
[GO TO CONTACT BLOCK]
MR_C3. Can you please provide the name of the medical records service, the name of a contact person, their telephone
number and title?
IF THIS PERSON CANNOT HELP, ASK TO BE TRANSFERRED TO SOMEONE WHO CAN AND RESTART THIS SECTION.
YES.........................= 1
NO...........................= 2
[IF MR_C3 = 1 GO TO CONTACT BLOCK,
IF MR_C2 = 2 GO TO EXIT SCREEN.]
[MR_D]CALL MR SERVICE
MR_D1. Have I reached [MEDICAL RECORDS SERVICE]?
PHONE NUMBER: [MEDICAL RECORDS SERVICE TELEPHONE NUMBER]
IF THE PERSON ON THE PHONE SAYS NO, VERIFY THAT YOU DIALED THE CORRECT NUMBER
IF THE NUMBER IS CORRECT, ASK IF THE PERSON ON THE PHONE KNOWS OF ANOTHER NUMBER FOR THE MEDICAL RECORDS SERVICE. IF THEY DO, GO TO THE CONTACT BLOCK AND EDIT THE INFORMATION FOR THE MEDICAL RECORDS SERVICE.
IF NO BETTER NUMBER IS AVAILABLE, SELECT “NO” BELOW.
YES.........................= 1
NO..........................= 2
[IF MR_D1 = 1 GO TO MR_D2,
IF MR_D1 = 2 GO TO EXIT]
MR_D2. We were referred to you by [PROVIDER] about [NUMBER FROM PATIENT LIST] of their patients who
received medical service in [FILL_YR]. I have [an] authorization form[s] for the release of medical records and would like to
speak to the person that can help me with that process.
if the person you need to talk to is unavailable attempt to get THEIR contact information via the CONTACT BLOCK and set an appointment if possible.
CONTINUE = 1
SERVICE DOES NOT MAINTAIN 2014 RECORDS FOR PROVIDER =2
NOT CLEAR WHO TO SPEAK TO; WRONG NUMBER = 3
[IF MR_D2= 1 GO TO mr_E1, ,
IF MR_D2=2 OR 3 GO TO EXIT SCREEN]
[MR_E]MR SERVICE: IDENTIFY POC
MR_E1. Hello, my name is (YOUR NAME).
I am calling on behalf of the U.S. Department of Health and Human Services.
We are conducting MEPS which is a study about how people in the United States use and pay for health care.
For quality assurance and training purposes, this call may be monitored.
POC: [POC NAME]
READ IF NECESSARY: I have [an] authorization form[s] for the release of medical records and would like to speak to the person that can help me with that process.
IF THIS PERSON CANNOT HELP, ASK TO BE TRANSFERRED TO SOMEONE WHO CAN.
CONTINUE, THIS PERSON CAN HELP.........................= 1
COLLECT CONTACT INFORMATION FOR SOMEONE ELSE..........................= 2
[IF MR_E1=1, GO TO MR_E2,
IF MR_E1=2, GO TO CONTACT BLOCK;]
MR_E2. We were referred to you by [PROVIDER] for information about one or more of (his/her/their) patients. At this
time, [NUMBER FROM PATIENT LIST] patient[s] signed an authorization form allowing us to contact you for information
about the care they received from [PROVIDER] in [FILL_YR].
I would like to fax the authorization form[s] to you, along with additional information explaining the study.
I need to be sure I have the correct information for the packet. Should I direct it to you?
READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S): In order to remain HIPAA compliant, I need to send you the authorization form[s] first. Once you have received the form[s], then we can arrange for the collection of the data.
YES.........................= 1
NO..........................= 2
[GO TO CONTACT BLOCK]
.
MR_E3. Can you please provide the name and number for the person who (needs to receive the courtesy packet/needs
to receive the forms) to approve the release of data?
YES.........................= 1
NO...........................= 2
[IF MR_E3 = 1 GO TO CONTACT BLOCK,
IF MR_E3 = 2 GO TO EXIT SCREEN]
[MR_F]DC: EXPLAIN NEXT STEPS
MR_F1. Once you have received the authorization form[s] you can send us the medical records by either fax or mail For each date of service in [FILL_YR], we are requesting information about the diagnoses and services, and the names of the physicians who treated each patient in [FILL_YR].
PROVIDER WILL RESPOND:
BY FAX 1
BY MAIL 2
GO TO MR_F2
MR_F2. Within the next 24 hours we will [fax/mail] you the authorization form[s] and include an instruction sheet. If you have any questions about what to send us, please call our toll-free number on the instruction sheet. We will call to verify that you received the authorization forms.
We may call again if other patients identify your practice as a source of medical services.
GO TO MR_F4;
If MR_F1=1 or 2, fill “We hope you can send the records to our office within two weeks.”
MR_F4. We are also interested in the charges and the summary of payments for each date of service in [FILL_YR]. Can you provide this information?
YES..................................1
NO....................................2
IF MR_F4=1 GO TO CONTACT BLOCK AND THEN MR_F5;
IF MR_F4=2 GO TO MR_F4a.
MR_F4a. Can you please provide the name and number for whom we should contact to obtain this information?
YES............................1
NO..............................2
[IF MR_F4a=1 GO TO CONTACT BLOCK ;
IF MR_F4a=2 GO TO MR_F5].
MR_F5. Lastly, we are interested in collecting the names and locating information for the providers who treated each patient while they received services in this facility during [FILL_YR]. Can you provide this information as well?
YES............................1
NO..............................2
[IF MR_F5=1 GO TO CONTACT BLOCK ;
IF MR_F5=2 GO TO MR_F5a.]
MR_F5a. Can you please provide the name and number for whom we should contact to obtain this information?
YES............................1
NO..............................2
[IF MR_F5a=1 GO TO CONTACT BLOCK ;
IF MR_F5a=2, GO TO exit screen;
[MR_G]VERIFY RECEIPT OF AFs
MR_G_Intro. May I please speak to [POC NAME]?
PERSON IS ON THE PHONE.........................= 1
PERSON IS NOT AVAILABLE..........................= 2
[POC NAME] should fill with the name flagged as primary from CONTACT BLOCK;
IF MR_G_Intro=1, GO TO MR_G1;
IF MR_G_Intro =2, GO TO APPOINTMENT SCREEN]
MR_G1. Hello, my name is (YOUR NAME). I am calling on behalf of the U.S. Department of Health and Human Services. For quality assurance and training purposes, this call may be monitored. We previously spoke about the MEPS study.
Did you receive the authorization form[s] we [faxed/mailed] to you?
YES, RECEIVED ALL = 1
YES, BUT PROBLEM REPORTED/NEEDS A RE-SEND = 2
NO = 3
IF MR_G1=1 and MR_F1 = 1 (FAX) OR 2 (MAIL) GO TO MR_G4;
IF MR_G1=2 OR 3, GO TO MR_G5]
MR_G4.
Our records indicate that you will [fax/mail] the records to us.
IF MR ONLY:
Please send in the complete medical records for all [FILL_YR] dates of service for each patient listed. The information we are attempting to collect from these records includes diagnosis and the names of providers who may have billed the patient separately from the hospital.
IF MR & PA:
Please send in the complete medical records and final billing records for all [FILL_YR] dates of service for each patient listed. The information we are attempting to collect from these medical records includes diagnosis and the names of providers who may have billed the patient separately from the hospital. Information we are attempting to collect for billing includes, charges, payments, and adjustments for each date of service. [IF THE POC MENTIONS UB04 OR CMS 1500, SAY:] We can use UB04/CMS1500 forms, but also need a final itemized statement that includes payments and adjustments so that we do not have to call back to obtain this information.
When will you send us these records?
DATE:_______
IF DATE IS SELECTED REPEAT THE DATE AND THE DAY OF THE WEEK
OR
________
(NUMBER)
MR_G4_1: Thank you. We will call you back if we do not receive the records by [FILL DATE FROM MR_G4 (CALCULATE DATE IF DAYS/WEEKS ENTERED)].
YOUR NEXT STEPS WILL BE TO EXIT THE CONTACT GUIDE AND CODE THE CASE AS “AFs RECEIVED. WAITING FOR RECORDS TO BE SENT”. THEN SET A CALL BACK AFTER THE RECORDS ARE EXPECTED SO WE CAN PROMPT AGAIN IF THEY STILL HAVE NOT BEEN RECEIVED.
MR_G4_2:
INTERVIEWER: USE THIS SCREEN WHEN PROMPTING FOR RECORDS
We were anticipating receiving (medical records/ medical and billing records) from you by [DATE/CALCULATED DATE FROM MR_G4], but my records show we have not received them. Have you sent the records to us?
YES............................1
NO..............................2
FILL DATE/CALCULATED DATE FROM MR_G4.
IF MR_G4_2 = 2 GO TO MR_G4_5
MR_G4_3: How did you send the records? Did you fax, mail hardcopies via express or regular mail, mail CDs via express or regular mail, or use healthport?
FAX..............................................................1
MAIL HARDCOPIES VIA EXPRESS MAIL...2
MAIL HARDCOPIES VIA REGULAR MAIL...3
MAIL CDs VIA EXPRESS MAIL...................4
MAIL CDs VIA REGULAR MAIL...................5
HEALTHPORT.............................................6
OTHER (Specify:__________________)…….7
IF POC IS SENDING CD: Was the password provided or did you send it separately?
MR_G4_4: What date did you send them?
DATE:_______
Thank you for sending them. The records are received in a separate department and it can take a few days to upload the documents into our system. We will investigate and call you back if we have further questions. We apologize for any inconvenience.
INTERVIEWER:
Disposition the case at Category: Refusals/Problems/Other with Event code 675-Case Requires Supervisor Review
Leave a detailed Call History comment after ending the call
Use “Difficult Case” sheet to capture Case ID and details and have a team lead or supervisor follow up and resolve within 24 hours
MR_G4_5
We need to obtain these records for the study as soon as possible. Is there something that can be done to speed up (or expedite) the process?
INTERVIEWER: LISTEN TO POC TO DETERMINE IF THERE IS ANYTHING WE CAN DO TO HELP FACILITATE THEM SENDING IN RECORDS. OFFER:
FTP AND SECURE E-MAIL
A FEDEX PICKUP FOR CASES THAT ARE ABOVE 15 PAIRS
When will you send us these records?
DATE:______________
IF DATE IS SELECTED REPEAT THE DATE AND DAY OF THE WEEK
OR
____________(NUMBER)
IF MR ONLY:
Please send in the complete medical records for all [FILL_YR] dates of service for each patient listed. The information we are attempting to collect from these records includes diagnosis and the names of providers who may have billed the patient separately from the hospital.
IF MR & PA:
Please send in the complete medical records and final billing records for all [FILL_YR] dates of service for each patient listed. The information we are attempting to collect from these medical records includes diagnosis and the names of providers who may have billed the patient separately from the hospital. Information we are attempting to collect for billing includes, charges, payments, and adjustments for each date of service. [IF THE POC MENTIONS UB04 OR CMS 1500, SAY:] We can use UB04/CMS1500 forms, but also need a final itemized statement that includes payments and adjustments so that we do not have to call back to obtain this information.
MR_G4_6: Thank you. We will call you back if we do not receive the records by [FILL DATE FROM MR_G4_5 (CALCULATE DATE IF DAYS/WEEKS ENTERED)].
INTERVIEWER: SET A CALL BACK AFTER THE RECORDS ARE EXPECTED SO WE CAN PROMPT AGAIN IF THEY STILL HAVE NOT BEEN RECEIVED.
GO TO EXIT SCREEN
MR_G5. I'm sorry. Let me re-send the authorization form[s] to you.
I need to be sure I have the correct information for the packet. Should I direct it to you?
YES = 1
NO = 2
IF PERSON ON PHONE WANTS TO PROVIDE DATA BEFORE RECEIVING AUTHORIZATION FORMS: In order to remain HIPAA compliant, I need to send you the authorization form[s] first. Once you have received the form[s], then we can arrange for the collection of the data.
[GO TO CONTACT BLOCK]
[MR_H]BAD MR SERVICE INFO.
MR_H1. ASK (BY NAME) TO SPEAK WITH THE POC WHO DEALS WITH THE EXTERNAL BILLING SERVICE
This is (YOUR NAME) calling on behalf of the U.S. Department of Health and Human Services.
For quality assurance and training purposes, this call may be monitored.
We previously spoke about the MEPS study. Thank you for providing the contact information for [MEDICAL RECORDS SERVICE NAME]. Unfortunately we were unable to locate [MEDICAL RECORDS SERVICE
NAME] with the contact information you provided. Could you please verify the contact information we currently have
for [MEDICAL RECORDS SERVICE NAME]?
[PRESENT MEDICAL RECORDS SERVICE CONTACT INFO HERE]
MEDICAL RECORDS SERVICE CONTACT INFO IS CORRECT =1
MEDICAL RECORDS SERVICE CONTACT INFO IS NOT CORRECT =2
[IF MR_H1=1, GO TO MR_H2;
IF MR_H1=2, GO TO CONTACT BLOCK, ]
MR_H2. That is currently the information we have on file. Do you know of any other way we can get in touch with [MEDICAL RECORDS SERVICE NAME]?
YES = 1
NO = 2
[IF MR_H2 = 1 GO TO CONTACT BLOCK, ;
[IF MR_H2=2 GO TO EXIT SCREEN]
[MR_I]ANY OTHER MR SERVICE?
MR_I1. ASK (BY NAME) TO SPEAK WITH THE POC WHO DEALS WITH THE EXTERNAL BILLING SERVICE
This is (YOUR NAME) calling on behalf of the U.S. Department of Health and Human Services.
For quality assurance and training purposes, this call may be monitored.
We previously spoke about the MEPS study. Thank you for providing the contact information for
[MEDICAL RECORDS SERVICE NAME]. We were able to locate [MEDICAL RECORDS SERVICE NAME] with the
information you provided. However, they reported that they did not maintain the medical records for
[PROVIDER(S)] in [FILL_YR]. Could you please check to see if another medical records service maintained
medical records for [PROVIDER(S)] in [FILL_YR]?
OTHER MEDICAL RECORDS SERVICE MAINTAINED RECORDS =1
NO OTHER MEDICAL RECORDS SERVICE MAINTAINED RECORDS =2
[IF MR_I1=1, GO TO CONTACT BLOCK,;
IF MR_I1=2, GO TO EXIT SCREEN]
[PA_A]CALL PROVIDER
PA_A1. Hello, have I reached [PROVIDER]?
PHONE NUMBER: [PROVIDER TELEPHONE NUMBER]
YES........................= 1
NO, BUT CAN RECORD A NEW NUMBER..........................= 2
NO, NEED TO TRACE THE CASE………............................= 3
[IF PA_A1 = 1 GO TO PA_A2,
IF PA_A1 = 2 GO TO CONTACT BLOCK,
IF PA_A1 = 3 GO TO EXIT]
PA_A2. I have [an] authorization form[s] for the release of billing and payment records and would like to speak to the person that can help me with that process.
IF RECORDS ARE KEPT BY AN EXTERNAL BILLING SERVICE, ASK TO SPEAK WITH THE PERSON IN THE OFFICE WHO DEALS WITH THE EXTERNAL BILLING SERVICE.
CONTINUE, THIS PERSON CAN HELP = 1
COLLECT CONTACT INFORMATION FOR SOMEONE ELSE = 2
NO BILLING DEPARTMENT; UNCLEAR WHO HANDLES BILLING = 3
[IF PA_A2= 1 GO TO PA_B1,
IF PA_A2=2, GO TO CONTACT BLOCK
IF PA_A2=3 GO TO EXIT SCREEN]
[PA _B]IDENTIFY DC POC
PA_B1. My name is (YOUR NAME).
I am calling on behalf of the U.S. Department of Health and Human Services.
We are conducting MEPS which is a study about how people in the United States use and pay for health care.
For quality assurance and training purposes, this call may be monitored.
POC: [POC NAME]
READ IF NECESSARY: I have [an] authorization form[s] for the release of billing and payment records and would like to speak to the person that can help me with that process.
IF THIS PERSON CANNOT HELP, ASK TO BE TRANSFERRED TO SOMEONE WHO CAN.
CONTINUE, THIS PERSON CAN HELP.........................= 1
COLLECT CONTACT INFORMATION FOR SOMEONE ELSE..........................= 2
[IF PA_B1=1, GO TO PA_B2,
IF PA_B1=2, GO TO CONTACT BLOCK;]
PA_B2 At this time, [NUMBER FROM PATIENT LIST] patient[s] identified [PROVIDER] as a source of health care during [FILL_YR]. [The/Each] patient signed an authorization form allowing us to contact you for information about the cost of the care they received from [PROVIDER] in [FILL_YR]. Much of the information we need is within the billing and payment records. Are the billing and payment records maintained in your office, or is an external billing service used?
OFFICE MAINTAINS THE INFORMATION = 1
OFFICE USES AN EXTERNAL BILLING SERVICE = 2
[IF PA_B2 = 1 GO TO PA_B2b,
IF PA_B2 = 2 GO TO PA_B2_1]
PA_B2_1. Are you the person who deals with the external billing service?
YES = 1
NO = 2
[If PA_b2_1 = 1, go to PA_C2,
if PA_b2_1 = 2, go to PA_b2a]
PA_B2a. I’ll need to collect the name and telephone number for the person in your office who deals with the external billing service.
NEXT BUTTON TAKES USER TO CONTACT_BLOCK
PA_B2b. DID THIS PERSON ON THE PHONE WITH YOU NOW MENTION THAT HE/SHE DOES NOT NEED AUTHORIZATION FORMS BECAUSE WE ALREADY PROVIDED THESE TO THE MEDICAL RECORDS DEPARTMENT?
NO, WE SHOULD SEND AUTHORIZATION FORMS TO THIS PERSON……………..1
YES, WE CAN SKIP SENDING AUTHORIZATION FORMS TO THIS PERSON………2
IF PA_B2b = 1 GO TO PA_B2c;
IF PA_B2b = 2 GO TO PA_B2c]
PA_B2c. [IF PA_B2b=1 FILL “I would like to fax the authorization form[s] to you, along with additional information explaining the study. I need to be sure I have the correct information for the packet. Should I direct it to you?”
[IF PA_b2b=2 FILL “I’ll need to fax you some basic information about the study. Should I address the fax to you?”
READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S): In order to remain HIPAA compliant, I need to send you the authorization form[s] first. Once you have received the form[s], then we can arrange for the collection of the data.
YES.........................= 1
NO...........................= 2
PA_B3. Can you please provide the name and number for the person who (needs to receive the courtesy packet/needs to receive the forms) to approve the release of data?
YES.........................= 1
NO..........................= 2
[IF PA_B3 = 1 GO TO CONTACT BLOCK,
IF PA_B3 = 2 GO TO EXIT SCREEN.]
[PA _C]IDENTIFY BILLING SERVICE
PA_C1. Hello, my name is (YOUR NAME). I am calling on behalf of the U.S. Department of Health and Human Services.
We are conducting MEPS which is a study about how people in the United States use and pay for health care.
For quality assurance and training purposes, this call may be monitored.
POC: [POC NAME]
READ IF NECESSARY: I have [an] authorization form[s] for the release of billing and payment records and would like to speak to the person that can help me get in touch with the external billing service that maintains your billing and payment records.
IF THIS PERSON CANNOT HELP, ASK TO BE TRANSFERRED TO SOMEONE WHO CAN.
CONTINUE, THIS PERSON CAN HELP.........................= 1
COLLECT CONTACT INFORMATION FOR SOMEONE ELSE........................= 2
[IF PA_C1=1, GO TO PA_C2,
IF PA_C1=2, GO TO CONTACT BLOCK]
[POC NAME] should fill with the name flagged as primary from CONTACT BLOCK;
PA_C2. READ IF NECESSARY: At this time, [NUMBER FROM PATIENT LIST] patient[s] identified [PROVIDER] as a
source of health care during [FILL_YR]. [The/Each] patient signed an authorization form allowing us to contact you for
information about the cost of the care they received from [PROVIDER] in [FILL_YR].
We should be able to get all of the information we need from the billing service.
We can also fax you a copy of the authorization form[s] for your files.
I need to be sure I have the correct information for the packet. Should I direct it to you?
READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S)]: In order to remain HIPAA compliant, I need to send you the authorization form[s] first. Once you have received the form[s], then we can arrange for the collection of the data.
YES.........................= 1
NO...........................= 2
[GO TO CONTACT BLOCK]
PA_C3. Can you please provide the name of the billing service, the name of a contact person, their telephone number and title?
YES.........................= 1
NO...........................= 2
IF THIS PERSON CANNOT HELP, ASK TO BE TRANSFERRED TO SOMEONE WHO CAN AND RESTART THIS SECTION.
[IF PA_C3 = 1 GO TO CONTACT BLOCK,
IF PA_C3 = 2 GO TO EXIT SCREEN.]
[PA _D]CALL BILLING SERVICE
PA_D1. Have I reached [BILLING SERVICE]?
PHONE NUMBER: [BILLING SERVICE TELEPHONE NUMBER]
IF THE PERSON ON THE PHONE SAYS NO, VERIFY THAT YOU DIALED THE CORRECT NUMBER.
IF THE NUMBER IS CORRECT, ASK IF THE PERSON ON THE PHONE KNOWS OF ANOTHER NUMBER FOR THE BILLING SERVICE. IF THEY DO, GO TO THE CONTACT BLOCK AND EDIT THE INFORMATION FOR THE BILLING SERVICE.
IF NO BETTER NUMBER IS AVAILABLE, SELECT “NO” BELOW.
YES.........................= 1
NO..........................= 2
[IF PA_D1 = 1 GO TO PA_D2,
IF PA_D1 = 2 GO TO EXIT SCREEN]
PA_D2. We were referred to you by [PROVIDER] about [NUMBER FROM PATIENT LIST] of their patients who
received medical service in [FILL_YR]. I have [an] authorization form[s] for the release of billing and payment records and would like to speak to the person that can help me with that process.
if the person you need to talk to is unavailable attempt to get THEIR contact information via the CONTACT BLOCK and set an appointment if possible.
CONTINUE = 1
SERVICE DOES NOT MAINTAIN [FILL_YR] RECORDS FOR PROVIDER =2
NOT CLEAR WHO TO SPEAK TO; WRONG NUMBER = 3
[IF PA_D2= 1 GO TO PA_E1, ,
IF PA_D2=2 OR 3, GO TO EXIT SCREEN]
[PA_E]BILLING SVC.: IDENTIFY POC
PA_E1Hello, my name is (YOUR NAME).
I am calling on behalf of the U.S. Department of Health and Human Services.
We are conducting MEPS which is a study about how people in the United States use and pay for health care.
For quality assurance and training purposes, this call may be monitored.
POC: [POC NAME]
READ IF NECESSARY: I have [an] authorization form[s] for the release of billing and payment records and would like to speak to the person that can help me with that process.
IF THIS PERSON CANNOT HELP, ASK TO BE TRANSFERRED TO SOMEONE WHO CAN.
CONTINUE, THIS PERSON CAN HELP.........................= 1
COLLECT CONTACT INFORMATION FOR SOMEONE ELSE..........................= 2
[IF PA_E1=1, GO TO PA_E2,
IF PA_E1=2, GO TO CONTACT BLOCK;]
PA_E2. We were referred to you by [PROVIDER] for information about one or more of (his/her/their) patients. At this
time, [NUMBER FROM PATIENT LIST] patient[s] signed an authorization form allowing us to contact you for information
about the care they received from [PROVIDER] in [FILL_YR]. For each date of service in [FILL_YR] we are asking for the
charges and the summary of payments.
I would like to fax the authorization form[s] to you, along with additional information explaining the study.
I need to be sure I have the correct information for the packet. Should I direct it to you?
READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S): In order to remain HIPAA compliant, I need to send you the authorization form[s] first. Once you have received the form[s], then we can arrange for the collection of the data.
YES.........................= 1
NO..........................= 2
[s]: If [NUMBER FROM PATIENT LIST] = 1, fill “ ”; ELSE fill “s”.
PA_E3. Can you please provide the name and number for the person who (needs to receive the courtesy packet/needs
to receive the forms) to approve the release of data?
YES.........................= 1
NO...........................= 2
[IF PA_E3 = 1 GO TO CONTACT BLOCK,
IF PA_E3 = 2 GO TO EXIT SCREEN]
[PA _F]DC: EXPLAIN NEXT STEPS
PA_F1. Once you have received the [authorization form[s]/information explaining the study] you can send us the billing and payment records by either fax or mail.” For each date of service in [FILL_YR], we are collecting the amounts charged for services before any adjustments or discounts, and the sources and amounts of payment.
PROVIDER WILL RESPOND:
BY FAX 1
BY MAIL 2
PA_F2. Within the next 24 hours we will [fax/mail] you the [authorization form[s]/information explaining the study] and include an instruction sheet. If you have any questions about what to send us, please call our toll-free number on the instruction sheet. We will call to verify that you received the authorization forms.
We may call again if other patients identify your practice as a source of medical services.]
pa_F4. We are also interested in collecting the names and locating information for the providers who treated each patient while they received services in this facility in [FILL_YR]. Can you provide this information as well?
YES............................1
NO..............................2
[IF pa_F4=1 GO TO CONTACT BLOCK,;
IF pa_F4=2 GO TO pa_F4a.]
pa_F4a. Can you please provide the name and number for whom we should contact to obtain this information?
YES............................1
NO..............................2
[IF pa_F4a=1 GO TO CONTACT BLOCK,;
IF pa_F4a=2 GO TO EXIT].
[PA _G]VERIFY RECEIPT OF AFs
PA_G_Intro. May I please speak to [POC NAME]?
PERSON IS ON THE PHONE.........................= 1
PERSON IS NOT AVAILABLE..........................= 2
[IF PA_G_Intro=1, GO TO PA_G1;
IF PA_G_Intro =2, GO TO APPOINTMENT SCREEN]
PA_G1. Hello, my name is (YOUR NAME). I am calling on behalf of the U.S. Department of Health and Human Services. For quality assurance and training purposes, this call may be monitored. We previously spoke about the MEPS study.
Did you receive the [authorization form[s]/information explaining the study] we [faxed/mailed] to you?
YES, RECEIVED ALL = 1
YES, BUT PROBLEM REPORTED/NEEDS A RE-SEND = 2
NO = 3
IF PA_G1=1 and PA_F1 = 1 (FAX) OR 2 (MAIL) GO TO PA_G4;
IF PA_G1=2 OR 3, GO TO PA_G5]
PA_G4.
Our records indicate that you will [fax/mail] the records to us.
IF PA ONLY: Please send in the final billing records for all [FILL_YR] dates of service for each patient listed. The information we are attempting to collect from these billing records includes charges, payments, and adjustments for each date of service.
IF MR & PA:
Please send in the complete medical records and final billing records for all [FILL_YR] dates of service for each patient listed. The information we are attempting to collect from these medical records includes diagnosis and the names of providers who may have billed the patient separately from the hospital. Information we are attempting to collect for billing includes, charges, payments, and adjustments for each date of service. [IF THE POC MENTIONS UB04 OR CMS 1500, SAY:] We can use UB04/CMS1500 forms, but also need a final itemized statement that includes payments and adjustments so that we do not have to call back to obtain this information.
When will you send us these records?
DATE:______________
IF DATE IS SELECTED REPEAT THE DATE AND DAY OF THE WEEK
OR
____________(NUMBER)
PA_G4_1. Thank you. We will call you back if we do not receive the records by [FILL DATE FROM PA_G4 (CALCULATE DATE IF DAYS/WEEKS ENTERED)].
YOUR NEXT STEPS WILL BE TO EXIT THE CONTACT GUIDE AND CODE THE CASE AS “AFs RECEIVED. WAITING FOR RECORDS TO BE SENT”. THEN SET A CALL BACK AFTER THE RECORDS ARE EXPECTED SO WE CAN PROMPT AGAIN IF THEY STILL HAVE NOT BEEN RECEIVED.
PA_G4_2
INTERVIEWER: USE THIS SCREEN WHEN PROMPTING FOR RECORDS
We were anticipating receiving (IF PA ONLY: billing and payment records / IF MR & PA: medical records and billing and payment records) from you by [DATE/CALCULATED DATE FROM PA_G4], but my records show we have not received them. Have you sent the records to us?
YES............................1
NO..............................2
IF PA_G4_2 = 2 GO TO PA_G4_5
PA_G4_3:
How did you send the records? Did you fax, mail hardcopies via express or regular mail, mail CDs via express or regular mail, or use healthport?
FAX..............................................................1
MAIL HARDCOPIES VIA EXPRESS MAIL...2
MAIL HARDCOPIES VIA REGULAR MAIL...3
MAIL CDs VIA EXPRESS MAIL...................4
MAIL CDs VIA REGULAR MAIL...................5
HEALTHPORT.............................................6
OTHER (Specify:__________________)…….7
IF POC IS SENDING CD: Was the password provided or did you send it separately?
PA_G4_4: What date did you send them?
DATE:_______
Thank you for sending them. The records are received in a separate department and it can take a few days to upload the documents into our system. We will investigate and call you back if we have further questions. We apologize for any inconvenience.
INTERVIEWER:
Disposition the case at Category: Refusals/Problems/Other with Event code 675-Case Requires Supervisor Review
Leave a detailed Call History comment after ending the call
Use “Difficult Case” sheet to capture Case ID and details and have a team lead or supervisor follow up and resolve within 24 hours
PA_G4_5
We need to obtain these records for the study as soon as possible. Is there something that can be done to speed up (or expedite) the process?
INTERVIEWER: LISTEN TO POC TO DETERMINE IF THERE IS ANYTHING WE CAN DO TO HELP FACILITATE THEM SENDING IN RECORDS. OFFER:
FTP AND SECURE E-MAIL
A FEDEX PICKUP FOR CASES THAT ARE ABOVE 15 PAIRS
When will you send us these records?
DATE:______________
IF DATE IS SELECTED REPEAT THE DATE AND DAY OF THE WEEK
OR
____________(NUMBER)
IF PA ONLY: Please send in the final billing records for all [FILL_YR] dates of service for each patient listed. The information we are attempting to collect from these billing records includes charges, payments, and adjustments for each date of service.
IF MR & PA:
Please send in the complete medical records and final billing records for all [FILL_YR] dates of service for each patient listed. The information we are attempting to collect from these medical records includes diagnosis and the names of providers who may have billed the patient separately from the hospital. Information we are attempting to collect for billing includes, charges, payments, and adjustments for each date of service. [IF THE POC MENTIONS UB04 OR CMS 1500, SAY:] We can use UB04/CMS1500 forms, but also need a final itemized statement that includes payments and adjustments so that we do not have to call back to obtain this information.
PA_G4_6: Thank you. We will call you back if we do not receive the records by [FILL DATE FROM PA_G4_5 (CALCULATE DATE IF DAYS/WEEKS ENTERED)].
INTERVIEWER: SET A CALL BACK AFTER THE RECORDS ARE EXPECTED SO WE CAN PROMPT AGAIN IF THEY STILLHAVE NOT BEEN RECEIVED.
GO TO EXIT SCREEN
PA_G5. I'm sorry. Let me re-send the [authorization form[s]/information explaining the study] to you.
I need to be sure I have the correct information for the packet. Should I direct it to you?
YES = 1
NO = 2
IF PERSON ON PHONE WANTS TO PROVIDE DATA BEFORE RECEIVING AUTHORIZATION FORMS: In order to remain HIPAA compliant, I need to send you the authorization form[s] first. Once you have received the form[s], then we can arrange for the collection of the data.
[PA _H]BAD BILLING SERVICE INFO.
PA_H1. ASK (BY NAME) TO SPEAK WITH THE POC WHO DEALS WITH THE EXTERNAL BILLING SERVICE
This is (YOUR NAME) calling on behalf of the U.S. Department of Health and Human Services.
For quality assurance and training purposes, this call may be monitored.
We previously spoke about the MEPS study. Thank you for providing the contact information for [BILLING SERVICE NAME]. Unfortunately we were unable to locate [BILLING SERVICE NAME] with the contact information you provided. Could you please verify the contact information we currently have for [BILLING SERVICE NAME]?
[PRESENT BILLING SERVICE CONTACT INFO HERE]
BILLING SERVICE CONTACT INFO IS CORRECT =1
BILLING SERVICE CONTACT INFO IS NOT CORRECT =2
[IF PA_H1=1, GO TO PA_H2;
IF PA_H1=2, GO TO CONTACT BLOCK, ]
PA_H2. That is currently the information we have on file. Do you know of any other way we can get in touch with [BILLING SERVICE NAME]?
YES = 1
NO = 2
[IF PA_H2 = 1 GO TO CONTACT BLOCK, ;
IF PA_H2=2 GO TO EXIT SCREEN.]
[PA _I]ANY OTHER BILLING SERVICE?
PA_I1. ASK (BY NAME) TO SPEAK WITH THE POC WHO DEALS WITH THE EXTERNAL BILLING SERVICE
This is (YOUR NAME) calling on behalf of the U.S. Department of Health and Human Services. For quality assurance and training purposes, this call may be monitored.
We previously spoke about the MEPS study. Thank you for providing the contact information for
[BILLING SERVICE NAME]. We were able to locate [BILLING SERVICE NAME] with the information you provided.
However, they reported that they did not maintain the billing and payment records for [PROVIDER(S)] in [FILL_YR]. Could you please check to see if another billing service maintained billing and payment records for [PROVIDER(S)] in [FILL_YR]?
OTHER BILLING SERVICE MAINTAINED RECORDS 1
NO OTHER BILLING SERVICE MAINTAINED RECORDS 2
[IF PA_I1=1, GO TO CONTACT BLOCK;
IF PA_I1=2, GO TO EXIT SCREEN]
[AO_A]PROVIDER/AO CONTACT
AO_A1READ IF NOT OBVIOUS: Have I reached [POC NAME]?
YES.........................= 1
NO...........................= 2
PHONE NUMBER: [POC TELEPHONE NUMBER]
YES........................= 1
NO, BUT CAN RECORD A NEW NUMBER..........................= 2
NO, NEED TO TRACE THE CASE………............................= 3
[IF AO_A1 = 1 GO TO AO_A2,
IF AO_A1 = 2 GO TO CONTACT BLOCK,
IF AO_A1 = 3 GO TO AO EXIT]
AO_A2.
IF AO POC WAS PROVIDED BY MEDICAL RECORDS OR PATIENT ACCOUNTS:
May I please speak to [POC NAME]?
IF NO AO POC WAS PROVIDED BY MEDICAL RECORDS OR PATIENT ACCOUNTS::
“Can I please speak to someone in the administrative office who can help me with contacting/locating information for providers?”
if the person you need to talk to is unavailable attempt to get THEIR contact information via the contact block and set an appointment if possible.
CONTINUE, THIS PERSON CAN HELP = 1
COLLECT CONTACT INFORMATION FOR SOMEONE ELSE = 2
UNCLEAR WHO TO SPEAK TO = 3
[IF AO_A2= 1 GO TO AO_A3,
IF AO_A2=2, GO TO CONTACT BLOCK,
IF AO_A2=3, GO TO EXIT SCREEN]
AO_A3. READ IF NECESSARY: (Hello,) my name is (YOUR NAME).
I am calling on behalf of the U.S. Department of Health and Human Services.
We are conducting MEPS which is a study about how people in the United States use and pay for health care.
POC: [POC NAME]
Earlier, your medical records department gave us information about the care that some of our study participants received at your facility and the names of the providers of that care. Now we need locating information for those providers and whether the charges for their services would be included in the hospital's bill or billed separately by the provider. Can you provide this information?
IF THIS PERSON CANNOT HELP, ASK TO BE TRANSFERRED TO SOMEONE WHO CAN.
CONTINUE, THIS PERSON CAN HELP.........................= 1
COLLECT CONTACT INFORMATION FOR SOMEONE ELSE..........................= 2
[IF AO_A3=1, GO TO AO_A4,
IF AO_A3=2, GO TO CONTACT BLOCK;]
AO_A4. For quality assurance and training purposes, this call may be monitored. If it is convenient for you, I can collect this locating information over the phone right now. I’d be happy to hold on while you get the information you need from your records.
WILL COMPLETE BY PHONE NOW = 1
WILL COMPLETE BY PHONE IN THE FUTURE = 2
[IF AO_A4=1 GO TO AO_A5;
IF AO_A4=2 GO TO AO_A4a]
AO_4a. I understand. What would be the best day and time to call you back to collect this information?
EARLY MORNING = 9AM
LATE MORNING = 11AM
EARLY AFTERNOON = 2PM
LATE AFTERNOON = 4PM
DATE:_________
R's TIME: AM/PM
TIMEZONE:
IF COMPLETE, GO TO EXIT SCREEN
SBD_CGINTRO. I want to ask about [PHYSICIAN NAME], whose specialty is [SPECIALTY]. This doctor was reported as someone who bills separately for services.
SBD_CG8a. Can you tell whether this physician bills separately or has charges included in your facility’s bill?
BILLS SEPARATELY = 1
CHARGES INCLUDED IN FACILITY BILL = 2
BILLING ARANGEMENT VARIES (SPECIFY) = 3
DON’T KNOW = 4
What is the business practice phone number and location for [FILL]?
Name of Group Practice (If applicable):
Phone:
Phone EXTENSION
NATIONAL PROVIDER ID
Group NPI:
Street:
City
State:
Zip:
SBD_CG8b.
Does this physician use a billing service or have billing contact information that is different than his or her business practice location?
YES 1 R_BILLSRVC
NO 2
[(IF R_BILLSRVC = 1 (YES), GO TO SBD_CG9;
IF R_BILLSRVC = 2 (NO), GO TO SBD_CG10;
DK/REF/RETRIEVABLE – GO TO SBD_CG10]
SBD_CG9
What is the billing contact information?
Name of Billing Service:
Phone of billing service
Address of billing service:
Street
City
State
Zip
Have you confirmed that the billing service name and contact information are accurate?
SBD_CG10. RECORD ANY NOTES AO GIVES ABOUT [PHYSICIAN NAME]
GO BACK TO SBD GRID.
AFTER ALL SBDs HAVE BEEN UPDATED, SELECTING NEXT WILL TAKE YOU TO SBD_CG11.
[IF SBD_CG11 = 1 GO TO EXIT SCREEN;
IF SBD_CG11 = 2 GO TO SBD_CG12.]
SBD_CG12. Who would be able to help me with the information for the remaining providers?
ADDITIONAL AO POC PROVIDED = 1
DK; NO ADDITIONAL AO POC PROVIDED = 2
IF SBD_CG12 = 1 GO TO CONTACT BLOCK, ;
OR IF SBD_CG12 = 2 GO TO EXIT SCREEN]
SECTION J: Gaining Permission: Talking Points
INTRODUCTION:
May I please speak to [POC NAME]?
Hello, my name is (YOUR NAME).
I am calling on behalf of the U.S. Department of Health and Human Services. We are conducting MEPS which is a study about how people in the United States use and pay for health care. For quality assurance and training purposes, this call may be monitored.
I recently spoke with {POC YOU ARE WORKING WITH FOR DATA COLLECTION} about the study. I explained that at this time, [NUMBER FROM PATIENT LIST] patient[s] identified [PROVIDER] as a source of health care during [FILL_YR]. [The/Each] patient signed an authorization form allowing us to contact you for information about the diagnoses and services provided by [PROVIDER] in [FILL_YR]. Much of the information we need is within the (billing and payment records/medical records).
{POC YOU ARE WORKING WITH FOR DATA COLLECTION} has agreed to participate and provide us with the information we are looking for, but has requested that we first send you a copy of the authorization form[s] in order to receive permission to release the data to us.
I’m calling to confirm that you are in fact the best person to receive the forms[s] and information about the study by fax, and confirm your contact information so that I can address the fax to you.
VERIFY PERMISSION PACKET RECEIPT:
May I please speak to [POC NAME]?
(Hello, my name is (YOUR NAME).) I am calling on behalf of the U.S. Department of Health and Human Services. We
previously spoke about the MEPS study. For quality assurance and training purposes, this call may be monitored. Did you receive the authorization form[s] we sent to you?
IF THE PERSON ON THE PHONE DID RECEIVE THE FORMS, ASK:
Do you have any questions or concerns about the study information or the forms we sent?
At this point may I follow-up with {POC YOU ARE WORKING WITH FOR DATA COLLECTION} about the release of data?
IF YOU ARE CLEARED TO SPEAK WITH THE POC YOU ARE WORKING WITH FOR DATA COLLECTION,
EXIT TO THE CMS, MAKE THE POC YOU ARE WORKING WITH FOR DATA COLLECTION THE PRIMARY POC ON THE POC SCREEN
CALL THEM USING
SECTION MR_G: VERIFY RECEIPT OF AFs IF DEALING WITH MEDICAL RECORDS
OR SECTION PA_G: VERIFY RECEIPT OF AFs IF DEALING WITH PATIENT ACCOUNTS.
IF THE PERSON ON THE PHONE DOES NOT GIVE YOU PERMISSION
EXIT TO THE CMS TO CODE THE CASE AS “CASE REQUIRES SUPERVISOR REVIEW” AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS
IF THE PERSON ON THE PHONE DID NOT RECEIVE THE FORMS, SAY
I'm sorry. Let me re-send the authorization form[s] to you.
GO TO THE CONTACT BLOCK BY PRESSING NEXT AND VERIFY THE CONTACT INFORMATION WE HAVE ON FILE, THEN
EXIT TO THE CMS AND TRIGGER A RE-SEND OF THE PERMISSION PACKET TO THIS PERSON
CONTACT BLOCK
CONTACT FIELDS
PROVIDER NAME:
MEDICAL RECORDS/BILLING SERVICE NAME:
POC FIRST NAME:
POC LAST NAME:
PHONE:
EXT:
TIMEZONE:
FAX:
VERIFY FAX:
E-MAIL:
TITLE:
DEPARTMENT:
ADDRESS:
CITY:
STATE:
ZIP:
FOLLOW-UP QUESTIONS
CB1. WILL YOU BE CALLING THIS PERSON NEXT?
YES
NO
CB2a. WHICH SECTIONS OF THE CONTACT GUIDE APPLY TO THIS POC?
MEDICAL RECORDS
PATIENT ACCOUNTS ***
ADMINISTRATIVE OFFICE
MEDICAL RECORDS AND PATIENT ACCOUNTS ***
MEDICAL RECORDS AND ADMINISTRATIVE OFFICE
PATIENT ACCOUNTS AND ADMINISTRATIVE OFFICE***
MEDICAL RECORDS, PATIENT ACCOUNTS AND ADMINISTRATIVE OFFICE POC ***
INTERVIEWER: IF THE PATIENT ACCOUNTS SECTION APPLIES TO THIS POC (CB2a = 2, 4, 6, or 7) PLEASE ASK CB2b, OTHWERISE GO TO CB3
(IF CB2a = 2, 4, 6, or 7 CONTINUE, OTHERWISE GO TO CB2
***CB2b Does this office handle records for…
[CHECK ALL THAT APPLY]
CB2_1a Physician billing
CB2_1b Outpatient billing
CB2_1c Inpatient/ER billing
CB2_1d All Facility billing
CB2_1e Billing that includes all professional and facility fees for all types of services: inpatient, ER, outpatient, and office visits, or
CB2_1f_OTH Some other type of billing (Specify:______________________)
CB2. WHAT TYPE OF POC IS THIS PERSON?
PROVIDER LEVEL GATEKEEPER
HANDLES RELEASE OF IN-HOUSE RECORDS
DEALS WITH IN-HOUSE RECORDS FOR MR
DEALS WITH IN-HOUSE RECORDS FOR PA
DEALS WITH MEDICAL RECORDS SERVICE
DEALS WITH EXTERNAL BILLING SERVICE
MEDICAL RECORDS SERVICE GATEKEEPER
EXTERNAL BILLING SERVICE GATEKEEPER
HANDLES RELEASE OF RECORDS FOR MEDICAL RECORDS SERVICE
HANDLES RELEASE OF RECORDS FOR EXTERNAL BILLING SERVICE
ADMINISTRATIVE OFFICE POC
HANDLES RELEASE OF IN-HOUSE RECORDS & IS ADMINISTRATIVE OFFICE POC
COURTESY PACKET RECIPIENT
PERMISSION PACKET RECIPIENT
NEW/UPDATED NAME FOR PROVIDER
POC FOR REMAINING PROVIDERS (SBDs)
CB3. WHAT TYPE OF PACKET ARE YOU SENDING?
FAX
MAIL
N/A
CB3A: COMMENTS
CB4. ADD ANOTHER POC?
YES
NO
BRANCH
TYPICAL CONTACT SEQUENCE BY SECTION:
INTERNAL BILLING: A, B, Contact Block, F, end call
EXTERNAL BILLING SERVICE: Call provider: A, B, C, Contact Block, end call
Call billing service: D, E, edit Contact Block, end call
VERIFY AFs WERE RECEIVED: Go to G
CLICK ON YOUR NEXT STEP
O 1 MR – IDENTIFY A POC AT THIS PROVIDER’S OFFICE (SECTION MR_B)
O 2 MR – IDENTIFY A POC WHO WORKS WITH EXTERNAL BILLING SERVICE (SECTION MR_C)
O 3 MR - CALL THE EXTERNAL BILLING SERVICE (SECTION MR_D)
O 4 MR – VERIFY AUTHORIZATION FORMS WERE RECEIVED (SECTION MR_G)
O 5 PA – IDENTIFY A POC AT THIS PROVIDER’S OFFICE (SECTION PA_B )
O 6 PA – IDENTIFY A POC WHO WORKS WITH EXTERNAL BILLING SERVICE (SECTION PA_C)
O 7 PA – CALL THE EXTERNAL BILLING SERVICE (SECTION PA_D)
O 8 PA – VERIFY AUTHORIZATION FORMS WERE RECEIVED (SECTION PA_G)
CALLBACK/APPOINTMENT SCREEN
Can you please provide me with a better time to call back in order to reach him/her?
EARLY MORNING = 9AM
LATE MORNING = 11AM
EARLY AFTERNOON = 2PM
LATE AFTERNOON = 4PM
DATE:_________ R's TIME: AM/PM
ALL GO TO EXIT FROM HERE
EXIT SCREEN
PRESS FINISH TO EXIT CONTACT GUIDE AND TO GO TO CASE MANAGEMENT SYSTEM.
DO NOT HANG UP UNTIL YOU GET TO CALL DISPOSITION SCREEN.
IF YOU NEED TO SEND A COURTESY OR PERMISSION PACKET:
SAVE EVENT CODE FOR FAX/MAIL PACKET TO THIS POC FIRST
RE-ENTER CONTACT GUIDE AND CALL THE BILLING SERVICE OR PERMISSION POC
SAVE EVENT CODE FOR FAX/MAIL PACKET FOR COURTESY OR PERMISSION PACKET
EXIT TO CMS BY PRESSING FINISH
Hospital Contact Guide
Page
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | MEDICAL EXPENDITURE PANEL SURVEY (MEPS) - MEDICAL PROVIDER COMPONENT (MPC) |
| Author | jstockdale |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |
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