Name
Email [cf7mls_step cf7mls_step-1 "Continue" ""]
Business Legal Name: DBA / Name Used Publicly:
Address Line 1 Address Line 2
City State/Province ZIP / Postal Code
Billing Address is Same as Business Address YesNo
[group billing-address clear_on_hide]
[/group]
Business Owned By: Title:
Group NPI: FEIN:
State License Number: Taxonomy Code:
[cf7mls_step cf7mls_step-2 "Back" "Next" "Step 2"]
Tentative Billing start date Number of Practice Locations
[field_group practice-address-locations id="address-locations-groups" tabindex:1] Address [/field_group] What specialties does your Practice cover? How many Providers are currently active? [field_group providers-group id="provider-groups" tabindex:1] Provider Details (Name, Title, and NPI): [/field_group]
Do you offer Telehealth or In-person visits, or both? ChooseTelehealth onlyIn-person onlyBoth Telehealth and In-person What is your current patient volume per month?
What is your average Billing / Collections per month? What ICD and CPT codes do you commonly bill? [cf7mls_step cf7mls_step-3 "Back" "Next" "Step 3"]
Name of the Practice Management Software (PMS) Name of the EHR
How are your charts currently being coded? ProvidersIn HouseOutsourced
Do you require coding support from MedVoice? YesNo
How often are claims submitted? ChooseDaily2-3 times/weekWeekly Are you currently experiencing high denial rates? If so, what are the known reasons?
Office contact to request Patient Information/Records
Person who is responsible and can send scanned documents of Payer correspondence on weekly basis and information/records of the Patient as and when needed for AR follow up [field_group representatives id="representatives" tabindex:1]
Name of the Representative: Phone number of the Representative: Email of the Representative:
[/field_group]
[cf7mls_step cf7mls_step-4 "Back" "Next" "Step 4"]
[field_group contracted-payers id="contracted-payers" tabindex:1]
Name of the Payer: Activation Date EndDate
[field_group sub-payers id="sub-payers" tabindex:1] Sub Plan - Name of the Payer: [/field_group] Provider IDs for Medicare and Medicaid Provider IDs for Medicare and Medicaid [cf7mls_step cf7mls_step-5 "Back" "Next" "Step 5"]
Name of Clearinghouse: Do you need help with setting up Clearinghouse? YesNo
[field_group top-payers id="top-payers" tabindex:1] Top Payer's Name [/field_group] Any ongoing Payer issues? [cf7mls_step cf7mls_step-6 "Back" "Next" "Step 6"]
What is your current average days in A/R?
Are there unpaid or denied claims you'd like us to review? YesNo
Provide details of unpaid or denied claims Please share your last 3 to 6 months A/R report [cf7mls_step cf7mls_step-7 "Back" "Next" "Step 7"]
Do you send Patient Statements currently? YesNo
Do you want us to manage Patient Billing? YesNo
Are Co-pays/Coinsurance collected at check-in? YesNo
Do you offer payment plans? YesNo[cf7mls_step cf7mls_step-8 "Back" "Next" "Step 8"]
Preferred frequency for reports from Medvoice WeeklyBi-weeklyMonthly
[field_group email-report id="email-report" tabindex:1] Who should receive Reports? (Add email addresses) [/field_group]
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Individual Provider (Name of the Physician)
Supervising Provider (Name of the Physician)
List of Payers that need to be billed under Individual/Supervising Provider [field_group special-billing-payers id="special-billing-payers" tabindex:1] [/field_group]
List of Payers that need the claims to be billed to TPA based on the Provider Contract/Specialty [field_group tpa_billing-payers id="tpa_billing-payers" tabindex:1] [/field_group] [cf7mls_step cf7mls_step-10 "Back" "Next" "Step 10"]
[cf7mls_step cf7mls_step-11 "Back" "Next" "Step 11"]
Admin access to EHR and Practice Management Software to MedVoice TeamClearing House AccessLock Box AccessPortal Access – For all carriers billed.
Additional Notes or Comments [cf7mls_step cf7mls_step-12 "Back" "Step 12"]
