Form #2 Office Based Contact Guide

MEDICAL EXPENDITURE PANEL SURVEY (MEPS) - MEDICAL PROVIDER COMPONENT (MPC)

Attachment 69

Contact Guide

FOR

Office BaseD doctoRS

REFERENCE YEAR 2014

[A]CALL PROVIDER

A1. Hello, have I reached the office of [PROVIDER]?)

PHONE NUMBER: [PROVIDER TELEPHONE NUMBER]

YES…………………………………………….........................= 1

NO, BUT CAN RECORD A NEW NUMBER..........................= 2

NO, NEED TO TRACE THE CASE………............................= 3

[IF A1 = 1 GO TO A2,

IF A1 = 2 GO TO CONTACT BLOCK,

IF A1 = 3 GO TO EXIT]

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 A2= 1 GO TO B1,

IF A2=2, GO TO CONTACT BLOCK

IF A2=3 GO TO EXIT SCREEN]

[B]IDENTIFY DC POC

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.

CONTINUE, THIS PERSON CAN HELP.........................= 1

COLLECT CONTACT INFORMATION FOR SOMEONE ELSE..........................= 2

[IF B1=1, GO TO B2,

IF B1=2, GO TO CONTACT BLOCK;]

B2. Thank you. First, can you confirm that this is a doctor's office and not a hospital?

YES, THIS IS A PHYSICIAN'S OFFICE, PUBLICLY-FUNDED CLINIC, OR URGENT CARE CENTER 1

NO, THIS IS A HOSPITAL, SATELLITE CLINIC, HOSPITAL OUTPATIENT DEPT, OR SURGI-CENTER 2

NO, THIS IS A HOME CARE PROVIDER 3

NO, THIS IS A LONG-TERM CARE FACILITY SUCH AS A NURSING HOME 4

NO, THIS IS SOMETHING ELSE (SPECIFY): 5

[IF B2 = 3 OR 4 GO TO B3a_1,

IF B2 = 2 GO TO B4,

ELSE CONTINUE TO B3]

B3. And is there at least one physician in the practice who is a Medical Doctor or a Doctor of Osteopathy?

ALL SPECIALTIES ARE CONSIDERED MD/DO EXCEPT FOR: DENTISTS, OPTOMETRISTS, CHRIOPRACTORS AND PODIATRISTS

YES = 1

NO = 2

GAVE A SPECIALTY = 3

[IF B3 = 1 or 3 GO TO B4,

IF B3 = 2 GO TO CONTINUE

B3_1:  Is this office under the supervision of an MD or a DO?

YES = 1

NO = 2

[IF B3_1= 1 (YES) GO TO B4.  

IF B3_1 = 2 (NO) CONTINUE

B3a.

WHAT KIND OF OFFICE IS THIS PROVIDER? [CODE ALL THAT APPLY]

1. PSYCHOLOGIST’S OFFICE;

2.  DENTIST’S OFFICE;

3. CHIROPRACTOR’S OFFICE;

4. PODIATRISTS’S OFFICE;

5. OPTOMETRIST’S (Eye Doctor) OFFICE;

6. STAND-ALONE NURSE PRACTITIONER’S OFFICE (NP);  

7. PHYSICAL THERAPIST’S OFFICE (PT);

8. OCCUPATIONAL THEREAPIST’S OFFICE (OT);

9.  OTHER (Specify)_______

I'm sorry. The information I was hoping to collect today is specific to doctor's offices. Because this is not a doctor's office one of my colleagues will be calling back to collect the necessary information.

CLICK NEXT TO GO TO THE EXIT SCREEN. ONCE YOU EXIT, CODE THE CASE AS “PROVIDER INELIGIBLE”

[GO TO EXIT SCREEN]

B3a_1: I'm sorry. The information I was hoping to collect today is specific to doctor's offices.

CLICK NEXT TO GO TO THE EXIT SCREEN. ONCE YOU EXIT, CODE THE CASE AS “PROVIDER INELIGIBLE”

[GO TO EXIT SCREEN]

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 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 B4 = 1 GO TO B4b,

IF B4 = 2 GO TO B4_1]

B4_1. Are you the person who deals with the external billing service?

YES = 1

NO = 2

[If b4_1 = 1, go to C2,

if b4_1 = 2, go to b4a]

B4a. I’ll need to collect the name and telephone number for the person in your office who deals with the external billing service.

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]

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 B5 = 1 GO TO CONTACT BLOCK,

IF B5 = 2 GO TO EXIT SCREEN.]

[C]IDENTIFY BILLING SERVICE

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 C1=1, GO TO C2,

IF C1=2, GO TO CONTACT BLOCK]

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]

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 C3 = 1 GO TO CONTACT BLOCK,

IF C3 = 2 GO TO EXIT SCREEN.]

[D]CALL BILLING SERVICE

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 D1 = 1 GO TO D2,

IF D1 = 2 GO TO EXIT]

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 2014 RECORDS FOR PROVIDER =2

NOT CLEAR WHO TO SPEAK TO; WRONG NUMBER = 3

[IF D2= 1 GO TO E1,

IF D2=2 OR 3, GO TO EXIT SCREEN]

[E]BILLING SERVICE: IDENTIFY POC

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 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 E1=1, GO TO E2,

IF E1=2, GO TO CONTACT BLOCK;]

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 cost of 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]

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 E3 = 1 GO TO CONTACT BLOCK,

IF E3 = 2 GO TO EXIT SCREEN]

[F]DC: EXPLAIN NEXT STEPS

F1. Once you have received the authorization form[s] [if # of patients is < or =25 and B2 = 1, show “we will call back to collect the data over the phone”, if # of patients is >25 or B2 DOES NOT = 1, show “you can send us the billing and payment records by either fax or mail, or we can call back to collect the data over the phone.”] For each date of service in [FILL_YR], we are requesting information about charges, payments, diagnoses, and services provided.

PROVIDER WILL RESPOND:

BY PHONE 1

BY FAX 2

BY MAIL 3

[IF F1 = 1 GO TO F2,

IF F1 = 2 GO TO F2,

IF F1 = 3 GO TO F2]

F2. Within the next 24 hours we will [fax/mail] you the authorization forms 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 will work with you to set up a good time to collect the data over the phone.

We may call again if other patients identify your practice as a source of medical services.]

[Instrument logic will be implemented so text only appears on screen when provider verification has not been completed:  Before we send you the form(s) I’ll need to determine that all of the providers I have listed were in fact associated with this health care practice in [FILL_YR].  I’m going to read you a list of providers; please tell me if each one was associated with this health care practice in [FILL_YR].]

GO TO EXIT;

[G]VERIFY RECEIPT OF AFs

G_Intro. May I please speak to [POC NAME]?

PERSON IS ON THE PHONE.........................= 1

PERSON IS NOT AVAILABLE........................= 2

[IF G_Intro=1, GO TO G1,

IF G_Intro =2, GO TO APPOINTMENT SCREEN]

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 B2 = 2 (Hospital) GO TO G4 (Obtain date we can expect records)

ELSE IF G1=1 and F1 (How provider will respond) = 1 (PHONE) GO TO G2 (Indicates whether will complete by phone now or at a later date), ELSE IF G1=1 and F1 = 2 (FAX) OR 3 (MAIL) GO TO G4 (Obtain date we can expect records);

ELSE GO TO G5 (Need to resend AFs)

G2. If it is convenient for you, we can just go ahead and complete the data forms together 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 G2=1 GO TO EXIT SCREEN;

IF G2=2 GO TO G3]

G3. I understand. What would be the best day and time to call you back to complete the data forms?

• 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

G4.

Our records indicate that you will [fax/mail] the records to us.

Please send in the complete billing records for all [FILL_YR] dates of service for each patient listed. The information we are attempting to collect from these records includes diagnosis, services, 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)

G4_1: Thank you. We will call you back if we do not receive the records by [FILL DATE FROM 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.

GO TO EXIT SCREEN

G4_2:

INTERVIEWER: USE THIS SCREEN WHEN PROMPTING FOR RECORDS

We were anticipating receiving billing records from you by [DATE/CALCULATED DATE FROM G4], but my records show we have not received them.  Have you sent the records to us? 

YES............................1

NO..............................2

IF G4_2 = 2 GO G4_5

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?

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

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)

Please send in the complete billing records for all [FILL_YR] dates of service for each patient listed. The information we are attempting to collect from these records includes diagnosis, services, 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.

G4_6: Thank you. We will call you back if we do not receive the records by [FILL DATE FROM 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

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.

[IF G5=1, GO TO CONTACT_BLOCK,

IF G5=2, GO TO CONTACT_BLOCK, ]

[H]BAD BILLING SERVICE INFO.

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 H1=1, GO TO H2,

IF H1=2, GO TO CONTACT BLOCK]

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 H2 = 1 GO TO CONTACT_BLOCK,

IF H2=2 GO TO EXIT]

[I]ANY OTHER BILLING SERVICE?

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 I1=1, GO TO CONTACT BLOCK,

IF I1=2, GO TO EXIT SCREEN]

[J]Gaining Permission

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 cost of the care they received from [PROVIDER] in [FILL_YR]. Much of the information we need is within the billing and payment 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 form[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 G: VERIFY RECEIPT OF AFs

  • 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:

GROUP/PRACTICE NAME:

BILLING SERVICE NAME:

POC FIRST NAME:

POC LAST NAME:

PHONE:

TIME ZONE:

EXT:

FAX:

VERIFY FAX:

E-MAIL:

TITLE:

DEPARTMENT:

ADDRESS:

CITY:

STATE:

ZIP:

FOLLOW-UP QUESTiONS

CB1. WILL YOU BE CALLING THIS PERSON NEXT?

1. YES

2. NO

CB2. WHAT TYPE OF POC IS THIS PERSON?

1. PROVIDER LEVEL GATEKEEPER

2. HANDLES RELEASE OF IN-HOUSE RECORDS

3. DEALS WITH EXTERNAL BILLING SERVICE

4. EXTERNAL BILLING SERVICE GATEKEEPER

5. HANDLES RELEASE OF RECORDS FOR EXTERNAL BILLING SERVICE

6. COURTESY PACKET RECIPIENT

7. PERMISSION PACKET RECIPIENT

8. NEW UPDATED NAME FOR PROVIDER

CB2a 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:______________________)

CB3. WHAT TYPE OF PACKET ARE YOU SENDING?

1. FAX

2. MAIL

3. N/A

CB3A: COMMENTS

CB4. ADD ANOTHER POC?

1. YES

2. NO

SET CALLBACK/APPOINTMENT

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

TIMEZONE:

ALL GO TO EXIT FROM HERE

EXIT SCREEN

PRESS FINISH TO EXIT CONTACT GUIDE AND GO TO CASE MANAGEMENT SYSTEM.

DO NOT HANG UP UNTIL YOU GET TO CALL DISPOSITION SCREEN.

IF POC RECEIVED AUTHORIZATION FORMS AND REPORT DATA BY PHONE NOW, ENTER EVENT CODE 441: AFs Received – Ready for Phone Data Collection

IF YOU NEED TO SEND A COURTESY OR PERMISSION PACKET:

1. SAVE EVENT CODE FOR FAX/MAIL PACKET TO THIS POC FIRST

2. RE-ENTER CONTACT GUIDE AND CALL THE BILLING SERVICE OR PERMISSION POC.

3. SAVE EVENT CODE FOR FAX/MAIL PACKET FOR COURTESY OR PERMISSION PACKET

EXIT

Office Based Doctors Contact guide Page 34 of 34