Form #5 Institution Contact Guide
Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC)
Attachment 71 MPC Institution Contact Guide
MPC Contact Guide/Screening Call
OMB: 0935-0118
MEDICAL EXPENDITURE PANEL SURVEY (MEPS) - MEDICAL PROVIDER COMPONENT (MPC)
Contact Guide
FOR
INSTITUTION 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]
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 ]
[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]
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. Can you confirm that this is a long-term care facility?
YES, THIS IS A LONG-TERM CARE FACILITY........................................1
NO, THIS IS NOT A LONG-TERM CARE FACILITY..........................................2
INCLUDE NURSING HOMES, REHABILITATION FACILITIES, LONG TERM UNITS OF HOSPITALS (SUCH AS A SKILLED NURSING FACILITY OR SNF UNIT)
[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 hospital – not a long term care unit, such as a
Skilled Nursing Facility, or.........................................................................5
Something else (SPECIFY)?.....................................................................6
IF RESPONDENT REPORTS LONG-TERM CARE UNIT, SUCH AS A SKILLED NURSING FACILITY, GO BACK TO ITEM MR_B2 ELIGIBILITY – VERIFY INSTITUTION AND CODE ACCORDINGLY.
[IF MR_B3a=1,2,3,4,5,6 GO TO MR_B3b;
MR_B3b. I'm sorry. The information I was hoping to collect today is specific to institutions and long-term care facilities. Because this facility is not one of these, one of my colleagues will be calling back to collect the necessary information.
CLICK NEXT TO GO TO THE EXIT . ONCE YOU EXIT, CODE THE CASE AS “PROVIDER INELIGIBLE”
[GO TO EXIT ]
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.
PRESS “NEXT” TO GO TO THE CONTACT BLOCK. ADD THE NEW POC TO THE CONTACT BLOCK AND CALL THEM USING SECTION MR_C: IDENTIFY MR SERVICE.
NEXT BUTTON TAKES USER TO THE CONTACT BLOCK
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 .]
[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?
YES.........................= 1
NO...........................= 2
IF THIS PERSON CANNOT HELP, ASK TO BE TRANSFERRED TO SOMEONE WHO CAN AND RESTART THIS SECTION.
[IF MR_C3 = 1 GO TO CONTACT BLOCK,
IF MR_C3 = 2 GO TO EXIT .]
[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 ]
[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 ]
[MR_F]DC: EXPLAIN NEXT STEPS
MR_F1. Once you have received the authorization form[s] [if # of patients is < or =25, show “we will call back to collect the data over the phone”, if # of patients is >25, show “you can send us the medical 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 the diagnoses and services, and the names of the physicians who treated each patient in [FILL_YR].
PROVIDER WILL RESPOND:
BY PHONE 1
BY FAX 2
BY MAIL 3
[IF MR_F1 = 1 GO TO MR_F2,
IF MR_F1 = 2 GO TO MR_F2,
IF MR_F1 = 3 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 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 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 facility in [FILL_YR]. I’m going to read you a list of providers; please tell me if each one was associated with this facility in [FILL_YR].]
GO TO MR_F4;
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 ;
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 ;
[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
IF MR_G_Intro=1, GO TO MR_G1;
IF MR_G_Intro =2, GO TO APPOINTMENT ]
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 (PHONE) GO TO MR_G2;
IF MR_G1=1 and MR_F1 = 2 (FAX) OR 3 (MAIL) GO TO MR_G4;
IF MR_G1=2 OR 3, GO TO MR_G5]
MR_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 MR_G2=1 GO TO EXIT ;
IF MR_G2=2 GO TO MR_G3.]
MR_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
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 STEP WILL BE TO EXIT THE CONTACT GUIDE AND CODE THE CASE AS “AFs RECEIVED. WAITING FOR RECORDS TO BE SENT”.
GO TO EXIT
MR_G4_2:
INTERVIEWER: USE THIS 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
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
NEXT WILL ROUTE TO EXIT
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 STILLHAVE NOT BEEN RECEIVED.
GO TO EXIT
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.
[IF G5=1, GO TO CONTACT BLOCK,
IF G5=2, 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 ]
[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 ]
file.
[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 ]
[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_b4_1 = 1, go to PA_C2,
if PA_b4_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.
PRESS “NEXT” TO GO TO THE CONTACT BLOCK. ADD THE NEW POC TO THE CONTACT BLOCK AND CALL THEM USING SECTION PA_C: IDENTIFY BILLING SERVICE.
NEXT BUTTON TAKES USER TO CONTACT_BLOCK
PA_B2b. DID THE PERSON ON THE PHONE MENTION THAT THEY DID NOT NEED TO RECEIVE AUTHORIZATION FORMS BECAUSE THEY HAVE ALREADY BEEN SENT TO MR?
NO, SEND AUTHORIZATION FORMS TO PA……………..1
YES, NO NEED TO SEND AUTHORIZATION FORM(S) TO PA POC………2
PROGRAMMER NOTES
IF PA_B2b = 1 GO TO PA_B2c;
IF PA_B2b = 2 GO TO PA_B2c]
[s]: If [NUMBER FROM PATIENT LIST] = 1, fill “ ”; ELSE fill “s”.
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
[go to contact block]
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 .]
[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 and 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]
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_C2 = 2 GO TO EXIT .]
[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 ]
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 2014 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 ]
[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 cost of 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
[GO TO CONTACT BLOCK]
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,
[PA _F]DC: EXPLAIN NEXT STEPS
PA_F1. Once you have received the [authorization form[s]/information explaining the study] [if # of patients is < or =25, show “we will call back to collect the data over the phone”, if # of patients is >25, 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 collecting the amounts charged for services before any adjustments or discounts, and the sources and amounts of payment.
PROVIDER WILL RESPOND:
BY PHONE 1
BY FAX 2
BY MAIL 3
[IF PA_F1 = 1 GO TO PA_F2,
IF PA_F1 = 2 GO TO PA_F2,
IF PA_F1 = 3 GO TO PA_F2]
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 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.]
pre_logic for pa_f4 & PA_4a:
ask only if mr_f5=2 and mr_f5a=2.
ELSE GO TO EXIT
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_F2=1 GO TO CONTACT BLOCK,;
IF pa_F2=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_F2a=1 GO TO CONTACT BLOCK,;
IF pa_F2a=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 ]
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 (PHONE) GO TO PA_G2;
IF PA_G1=1 and PA_F1 = 2 (FAX) OR 3 (MAIL) GO TO PA_G4;
IF PA_G1=2 OR 3, GO TO PA_G5]
PA_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 PA_G2=1 GO TO EXIT ;
IF PA_G2=2 GO TO PA_G3]
PA_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
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 STEP WILL BE TO EXIT THE CONTACT GUIDE AND CODE THE CASE AS “AFs RECEIVED. WAITING FOR RECORDS TO BE SENT”.
GO TO EXIT
PA_G4_2
INTERVIEWER: USE THIS 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
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.
[IF PA_G5=1, GO TO CONTACT BLOCK,
IF PA_G5=2, GO TO CONTACT BLOCK, ]
[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 .]
[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 ]
[AO_A]PROVIDER/AO CONTACT
AO_A1. Have I reached [POC NAME]?
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 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 ]
AO_A3. 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.
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 facility’s bill or billed separately by the provider. Can you provide this information?
POC: [POC NAME]
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
SBD SUB ROUTINE
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
SBD_CG7. 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]
DK/REF/RETRIEVABLE – DONE WITH FORM]
GO BACK TO SBD GRID.
[IF SBD_CG11 = 1 GO TO EXIT ;
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 ]
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 (medical records/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] for the patients 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.
GO TO CONTACT BLOCK
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 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
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
If CB2a=2, 4, 6 or 7 then skip MR_F4 about who can provide PA data
If CB2a=3, 5, 6 or 7 then skip MR_F5 about who can provide SBD contact info
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
| 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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