Form Approved
OMB Number 0935-0118
Expiration Date 01/31/2013

MEDICAL PROVIDER COMPONENT
FOR REFERENCE YEAR 2010

CONTACT GUIDE FOR OFFICE-BASED PROVIDERS

VERSION 1.1

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

MEDICAL PROVIDER COMPONENT
FOR REFERENCE YEAR 2010

CONTACT GUIDE FOR OFFICE-BASED PROVIDERS

SECTION A: CALL PROVIDER

A1. [A1] (READ IF NOT OBVIOUS) Have I reached (PROVIDER)?

• IF YOU REACH AN IVR OR MENU, SELECT THE OPTION THAT WILL MOST LIKELY CONNECT YOU TO A PERSON (SUCH AS AN OPERATOR),
  -OR- SELECT A DEPARTMENT THAT SOUNDS LIKE IT HAS THE INFORMATION WE NEED.
  
  
• 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 PROVIDER. IF THEY DO, GO TO THE CONTACT BLOCK AND EDIT THE INFORMATION FOR THE PROVIDER.
  
  
• IF NO BETTER NUMBER IS AVAILABLE, SELECT “NO” BELOW.
  
  
• IF YES, CONTINUE TO A2
  
  
• IF NO, VERIFY TELEPHONE NUMBER, ADDRESS, AND NAME OF PROVIDER. IF PROVIDER IS DIFFERENT, RECORD PROBLEM AND TERMINATE CALL. CONTACT DIRECTORY ASSISTANCE. IF NO BETTER TELEPHONE NUMBER CAN BE FOUND, MARK FOR SUPERVISOR REVIEW.
  
  

A2. [A2] I have [an] authorization form[s] for the release of billing 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.

• 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 = 1 (GO TO B1)
NO BILLING DEPARTMENT; NOT CLEAR WHO TO SPEAK TO = 2 (GO TO EXIT SCREEN).

SECTION B: IDENTIFY DC POC
B1. [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. For quality assurance and training purposes, this call may be monitored.

(READ IF NECESSARY: I have [an] authorization form[s] for the release of billing records and would like to speak to the person that can help me with that process.)

• IF THE PERSON YOU ARE CALLING DID NOT ANSWER, RE-READ THE INTRO WHEN YOU BEGIN SPEAKING WITH THEM.

• IF THE PERSON ON THE PHONE STATES THAT THEY ARE NOT THE CORRECT PERSON TO GET THE INFORMATION FROM, ASK THEM TO TRANSFER YOU TO THE CORRECT PERSON,
  -OR- ASK FOR THE NAME AND TELEPHONE NUMBER OF THE PERSON WE NEED TO SPEAK WITH - ENTER THIS INTO THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

PERSON IS ON THE PHONE.........................= 1 (GO TO B2)
PERSON IS NOT AVAILABLE/CALL BACK..........................= 2 (GO TO APPOINTMENT SECTION)

B2. [A3] First, let me verify that this is a doctor's office and not a hospital.

___ PHYSICIAN'S OFFICE, PUBLICLY-FUNDED CLINIC, URGENT CARE CENTER CONTINUE TO B3

___ HOSPITAL, HOSPITAL SATELLITE CLINIC, HOSPITAL OUTPATIENT DEPARTMENT, SURGI-CENTER, GO TO B3A.

___ HOME CARE PROVIDER, GO TO B3A.

___ LONG-TERM CARE FACILITY SUCH AS A NURSING HOME, GO TO B3A.

___ SOMETHING ELSE (SPECIFY:______), GO TO B3A.

YES ....................................... 1 (GO TO B4).
NO ........................................ 2 (GO TO B3a).
GAVE A SPECIALTY .......... 3 (GO TO B4).

B3a.[A4] 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.

END CONTACT, CODE AS PROVIDER NOT ELIGIBLE

B4. [A6] At this time, [NUMBER FROM PATIENT LIST] patient(s) identified (PROVIDER) as a source of health care during 2010. (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 2010. Much of the information we need is within the billing records. Are the billing records maintained in your office, or is an external billing service used?

• IF ASKED, READ PATIENT NAMES AND OTHER IDENTIFYING INFORMATION..

• IF THE PERSON ON THE PHONE IS NOT SURE, ASK TO SPEAK WITH/BE TRANSFERRED TO SOMEONE WHO WOULD KNOW ABOUT THE BILLING RECORDS FROM 2010 AND RESTART THIS SECTION.
  -OR-
  ASK FOR THE NAME AND TELEPHONE NUMBER OF THE PERSON WE NEED TO SPEAK WITH -
  ENTER THIS INTO THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

  • OFFICE MAINTAINS THE INFORMATION: (GO TO B4b).

  • OFFICE USES AN EXTERNAL BILLING SERVICE: (GO TO B4_1).

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

YES = 1 (GO TO C2).
NO = 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.

[GO TO CONTACT BLOCK]

B4b. [A7] 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 fax cover page. Should I direct it to you?

IF YES, GO TO CONTACT BLOCK.

IF NO, PROBE TO FIND OUT IF SOMEONE ELSE WILL:

1. PROVIDE THE DATA,
2. JUST NEEDS A COURTESY PACKET, OR,
3. HAS TO GIVE PERMISSION.

• IF PERSON ON THE PHONE IS CONCERNED ABOUT RECEIVING A FAX, EXPLAIN THAT IT IS POSSIBLE TO SEND THE AUTHORIZATION FORMS IN THE MAIL.

• YOU WILL NOW BE TAKEN TO THE CONTACT BLOCK.

• IF THE PERSON ON THE PHONE WILL PROVIDE DATA, ADD OR EDIT THEIR CONTACT INFORMATION
• IF SOMEONE ELSE WILL PROVIDE THE DATA, ADD THE NEW POC’S CONTACT INFORMATION



• 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.

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 (GO TO CONTACT BLOCK)

NO..........................= 2 (GO TO EXIT SCREEN. CODE THE CASE AS “CASE REQUIRES SUPERVISOR REVIEW” AND ENTER A PROBLEM REPORT.)

• IF PERSON ON PHONE SAYS YES, YOU WILL BE TAKEN TO THE CONTACT BLOCK. ADD THE PERSON WHO NEEDS THE PERMISSION/COURTESY PACKET TO THE CONTACT BLOCK, THEN GO TO
  SECTION F: DC: EXPLAIN NEXT STEPS.

IF PERSON ON PHONE SAYS NO, YOU WILL BE TAKEN TO THE EXIT SCREEN. BE SURE TO CODE THE CASE AS “CASE REQUIRES SUPERVISOR REVIEW” AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.

SECTION C: IDENTIFY BILLING SERVICE
C1. (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. For quality assurance and training purposes, this call may be monitored.

(READ IF NECESSARY: I have [an] authorization form[s] for the release of billing records and would like to speak to the person that can help me get in touch with the external billing service that maintains your records.)

• IF THE PERSON YOU ARE CALLING DID NOT ANSWER, RE-READ THE INTRO WHEN YOU BEGIN SPEAKING WITH THEM.

• IF THE PERSON ON THE PHONE STATES THAT THEY ARE NOT THE CORRECT PERSON TO GET THE INFORMATION FROM, ASK THEM TO TRANSFER YOU TO THE CORRECT PERSON, -OR- ASK FOR THE NAME AND TELEPHONE NUMBER OF THE PERSON WE NEED TO SPEAK WITH – ENTER THIS INTO THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

  PERSON IS ON THE PHONE...= 1 (GO TO C2)
  PERSON IS NOT AVAILABLE/CALL BACK....= 2 (GO TO APPOINTMENT SECTION)

C2. (READ IF NECESSARY: At this time, [NUMBER FROM PATIENT LIST] patient[s] identified [PROVIDER] as a
source of health care during 2010. [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 2010.)

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?

• IF PERSON ON PHONE SAYS NO, PROBE TO FIND OUT IF SOMEONE ELSE:
1. DEALS WITH THE EXTERNAL BILLING SERVICE,
2. JUST NEEDS A COURTESY PACKET, OR,
3. HAS TO GIVE PERMISSION.


• YOU WILL NOW BE TAKEN TO THE CONTACT BLOCK.
  
• IF THE PERSON ON THE PHONE WILL PROVIDE DATA, ADD OR EDIT THEIR CONTACT INFORMATION
• IF SOMEONE ELSE WILL PROVIDE THE DATA, ADD THE NEW POC’S CONTACT INFORMATION
• IF ADDING A COURTESY PERMISSION PACKET RECIPIENT, ADD/EDIT BOTH POCS TO THE CONTACT BLOCK.

  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 (GO TO CONTACT BLOCK)
NO..........................= 2 (GO TO EXIT SCREEN)

• IF PERSON ON THE PHONE SAYS YES, ADD THE NEW PERSON TO THE CONTACT BLOCK, then exit and call the billing service.
  
  
• IF PERSON ON PHONE SAYS NO, ask to speak with someone who can provide this information AND RESTART THIS SECTION. If no one can, exit and BE SURE TO CODE THE CASE AS “CASE REQUIRES SUPERVISOR REVIEW” AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.

SECTION D: CALL BILLING SERVICE
D1. [N/A] (READ IF NOT OBVIOUS: (Hello) Have I reached (BILLING SERVICE)?)

• IF YOU REACH AN IVR OR MENU, SELECT THE OPTION THAT WILL MOST LIKELY CONNECT YOU TO A PERSON (SUCH AS AN OPERATOR),

  -OR- SELECT A DEPARTMENT THAT SOUNDS LIKE IT HAS THE INFORMATION WE NEED.
  

• 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.

  IF YES, CONTINUE WITH D2.

  IF NO, VERIFY TELEPHONE NUMBER, ADDRESS, AND NAME OF BILLING SERVICE. IF BILLING SERVICE IS DIFFERENT, RECORD PROBLEM AND TERMINATE CALL. GO TO EXIT.
  _______________________________________________________________________
  _______________________________________________________________________

D2. [A12]  (Hello) We were referred to you by (PROVIDER) about [NUMBER FROM PATIENT LIST] of their patients who received medical service in 2010. I have [an] authorization form[s] for the release of billing 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 (GO TO E1.)
SERVICE DOES NOT MAINTAIN 2010 RECORDS FOR PROVIDER = 2 (GO TO EXIT SCREEN)
NOT CLEAR WHO TO SPEAK TO; WRONG NUMBER = 3 (GO TO EXIT SCREEN)

SECTION E: BILLING SERVICE: IDENTIFY POC
E1. (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. For quality assurance and training purposes, this call may be monitored.

(READ IF NECESSARY: I have [an] authorization form[s] for the release of billing records and would like to speak to the person that can help me with that process.)

• IF THE PERSON YOU ARE CALLING DID NOT ANSWER, RE-READ THE INTRO WHEN YOU BEGIN SPEAKING WITH THEM.
  
  
• IF THE PERSON ON THE PHONE STATES THAT THEY ARE NOT THE CORRECT PERSON TO GET THE INFORMATION FROM, ASK THEM TO TRANSFER YOU TO THE CORRECT PERSON AND RESTART THIS SECTIO N,
  -OR-
  ASK FOR THE NAME AND TELEPHONE NUMBER OF THE PERSON WE NEED TO SPEAK
  WITH - ENTER THIS INTO THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

PERSON IS ON THE PHONE....= 1 (GO TO E2)
PERSON IS NOT AVAILABLE/CALL BACK... = 2 (GO TO APPOINTMENT SCREEN)

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 2010.

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 PERSON ON PHONE SAYS NO, PROBE TO FIND OUT IF SOMEONE ELSE WILL:
1. PROVIDE THE DATA,
2. JUST NEEDS A COURTESY PACKET, OR
3. HAS TO GIVE PERMISSION.
   
   
• IF ASKED, READ PATIENT NAMES AND OTHER IDENTIFYING INFORMATION.
  
  
• IF PERSON ON THE PHONE IS CONCERNED ABOUT RECEIVING A FAX, EXPLAIN THAT IT IS POSSIBLE TO SEND THE AUTHORIZATION FORMS IN THE MAIL.
  
  
• YOU WILL NOW BE TAKEN TO THE CONTACT BLOCK.
  • IF THE PERSON ON THE PHONE WILL PROVIDE DATA, ADD OR EDIT THEIR CONTACT INFORMATION
  • IF SOMEONE ELSE WILL PROVIDE THE DATA, ADD THE NEW POC’S CONTACT INFORMATION
  
  
• 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 (GO TO CONTACT BLOCK)
NO = 2 (GO TO EXIT SCREEN)

• IF PERSON ON PHONE SAYS YES, YOU WILL BE TAKEN TO THE CONTACT BLOCK. ADD THE PERSON WHO NEEDS THE PERMISSION/COURTESY PACKET TO THE CONTACT BLOCK, THEN GO TO SECTION F: DC: EXPLAIN NEXT STEPS.
  
  
• IF PERSON ON PHONE SAYS NO, BE SURE TO CODE THE CASE AS “CASE REQUIRES SUPERVISOR REVIEW” AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.
  
  

(In order for permission to be granted, we will send the authorization forms as a part of a study packet.)

IF THE PERSON ON THE PHONE EXPRESSES A CONCERN ABOUT PROVIDING DATA OVER THE PHONE SAY “You can also send us the billing records by either fax or mail.”

PROVIDER WILL RESPOND:

BY PHONE....................................................................... 1 (GO TO F2).
BY FAX............................................................................ 2 (GO TO F3).
BY MAIL........................................................................... 3 (GO TO F3).

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 the information we will need, please call our toll-free number on the instruction sheet. We will allow time for you to receive and review the authorization form[s], and then we will call you back to verify that you have received the form[s]. When we call back, we’ll also work with you to set up a good time to collect the data over the phone (once you’ve received permission to release the data).

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

YOU WILL NOW BE TAKEN TO THE EXIT SCREEN AND THEN TO THE CMS.

[GO TO EXIT]

F3.  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 you back to verify that you have received the form[s]. We hope you can send the records to our office within two weeks.

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

YOU WILL NOW BE TAKEN TO THE EXIT SCREEN AND THEN TO THE CMS.

[GO TO EXIT]

SECTION G: VERIFY RECEIPT OF AFS
G_Intro.  [A16]  May I please speak to (POC)?

PERSON IS ON THE PHONE.........................= 1 (GO TO G1)
PERSON IS NOT AVAILABLE........................= 2 (GO TO APPOINTMENT SCREEN)

G1. [A16]  (Hello, my name is (YOUR NAME).) I am calling on behalf of the U.S. Department of Health and Human Services. For quality and training purposes, this call may be monitored.

(We’ve confirmed that the authorization form[s] we sent in order to receive permission for the release of information [have/has] been received.)

We previously spoke about the MEPS study. Did you receive the authorization form(s) we (faxed/mailed)?

YES, RECEIVED ALL .................1 (GO TO G2 IF MODE=PHONE; GO TO G4 IF MODE=FAX OR MAIL)
YES, BUT PROBLEM REPORTED/NEEDS A RE-SEND ................. 2 (GO TO G5)
NO ................... 3 (GO TO G5)

G2.  [A21]  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 (GO TO EXIT SCREEN)
WILL COMPLETE BY PHONE IN THE FUTURE.......................... 2 (GO TO G3)

IF THE POC WANTS TO COMPLETE BY PHONE NOW, YOU WILL EXIT THE CONTACT GUIDE AND RETURN TO CMS. CODE THE CASE AS “AUTHORIZATION FORMS RECEIVED - READY FOR PHONE DATA COLLECTION”. THEN, PROCEED TO THE PATIENT LISTING SCREEN TO BEGIN EVENT FORM DATA COLLECTION.

G3.  [A23]  I understand. What would be the best day and time to call you back to complete the data forms?

• PROBE FOR THE BEST DATE AND TIME.
• IF THE POC IS HESITANT TO PROVIDE AN EXACT TIME OR DATE:
  -ASK WHICH DAY OF THE WEEK IS BEST
  -ASK WHICH SECTIONS OF A DAY (MORNING, AFTERNOON) ARE BEST AND USE THE FOLLOWING GUIDELINES FOR SCHEDULING:
• EARLY MORNING = 9AM
• LATE MORNING = 11AM
• EARLY AFTERNOON = 2PM
• LATE AFTERNOON = 4PM

DAY:___________  DATE:_________  R's TIME:_____________  AM/PM

[GO TO EXIT SCREEN]

G4.  [N/A]  Our records indicate that you will (fax/mail) the records to us. We hope you can do so within two weeks.

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 SCREEN]

G5.  [A17] I'm sorry. Let me (re-fax/re-send) the authorization form(s) to you. I need to be sure that I have the correct information for the packet. Should I direct it to you?

YES ............................................................. 1 (GO TO CONTACT BLOCK).
NO ............................................................... 2 (GO TO CONTACT BLOCK).

• IF ASKED, READ PATIENT NAMES AND OTHER IDENTIFYING INFORMATION.
  
  
• 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.
  
  
• CLICK NEXT TO PROCEED TO THE CONTACT BLOCK AND ADD OR EDIT CONTACT INFORMATION FOR THE POC WHO SHOULD RECEIVE THE PACKET. THEN EXIT THE CONTACT GUIDE AND CODE THE CASE IN CMS.
  
  

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). Unfortunately we were unable to locate (BILLING SERVICE) with the information you provided. Could you please verify the contact information we currently have for (BILLING SERVICE)?

NAME OF BILLING SERVICE:____________
CONTACT NAME: _____________________
TELEPHONE NUMBER: (______)__________ EXT: _____
TITLE: ________________________________

BILLING SERVICE CONTACT INFO IS CORRECT =1 (GO TO H2).
BILLING SERVICE CONTACT INFO IS NOT CORRECT =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]?

IF PERSON ON PHONE SAYS NO, BE SURE TO CODE THE CASE AS “CASE REQUIRES SUPERVISOR REVIEW” AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.

YES = 1 (GO TO CONTACT_BLOCK).
NO = 2 (GO TO EXIT SCREEN).

SECTION 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). We were able to locate (BILLING SERVICE) with the information you provided. However, they reported that they did not maintain the billing records for (PROVIDER(S)) in 2010. Could you please check to see if another billing service provided billing records for (PROVIDER(S)) in 2010?

OTHER BILLING SERVICE MAINTAINED RECORDS.................. 1 (GO TO CONTACT BLOCK).
NO OTHER BILLING SERVICE MAINTAINED RECORDS............ 2 (GO TO EXIT SCREEN).

IF PERSON ON PHONE SAYS NO, BE SURE TO CODE THE CASE AS “CASE REQUIRES SUPERVISOR REVIEW” AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS.

CONTACT BLOCK

IF YOU ARE BEING REFERRED TO A NEW POC BY SOMEONE ELSE, COLLECT ONLY NAME AND PHONE NUMBER.

IF YOU WOULD LIKE TO EDIT OR VERIFY INFORMATION FOR A POC YOU HAVE ALREADY COLLECTED INFORMATION FOR, THEIR NAME IN THE TABLE ABOVE.

IF UPDATING OR VERIFYING A POC FOR SENDING A MAIL/FAX PACKET TRY TO COLLECT/ VERIFY ALL FIELDS.

IF GIVEN INFORMATION FOR SOMEONE OTHER THAN THE PERSON ON THE PHONE, ALWAYS ASK TO BE TRANSFERRED TO THAT PERSON.

PROVIDER NAME:
BILLING SERVICE NAME:
POC FIRST NAME:
POC LAST NAME:
PHONE:
EXT:
FAX:
VERIFY FAX:
TITLE:
DEPARTMENT:
ADDRESS:
CITY:
STATE:
ZIP:

FOLLOW-UP QUESTiONS
CB1.  WORK WITH THIS POC ON THE NEXT STEP/CALL?

1. YES
2. NO

CB2.  WHAT TYPE OF POC DID YOU ENTER INFORMATION FOR?

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

CB3.  WHAT TYPE OF PACKET ARE YOU SENDING?

IF THE PERSON ON THE PHONE DID NOT EXPRESS A CONCERN ABOUT RECEIVING A FAX, SAY:
“To confirm, I will be sending the authorization forms to you by fax..”

IF THE PERSON ON THE PHONE DID EXPRESS A CONCERN ABOUT RECEIVING A FAX, SAY:
“To confirm, I will be sending the authorization forms to you by mail.”

1. FAX
2. MAIL

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?

• PROBE FOR THE BEST DATE AND TIME.
  
  
• IF THE PERSON ON THE PHONE IS HESITANT TO PROVIDE AN EXACT TIME OR DATE:
  -ASK WHICH DAY OF THE WEEK IS BEST
  -ASK WHICH SECTIONS OF A DAY (MORNING, AFTERNOON) ARE BEST AND USE THE FOLLOWING GUIDELINES FOR SCHEDULING:
• EARLY MORNING = 9AM
• LATE MORNING = 11AM
• EARLY AFTERNOON = 2PM
• LATE AFTERNOON = 4PM

DATE: _________  R's TIME: _____________ AM/PM

[GO TO EXIT SCREEN]

EXIT SCREEN

PRESS “FINISH” TO EXIT THE CONTACT GUIDE AND ENTER THE CASE MANAGEMENT SYSTEM
DO NOT HANG UP UNTIL YOU REACH THE CALL DISPOSITION SCREEN.

• IF A PERMISSION PACKET MUST BE SENT, YOU MUST DO THE FOLLOWING:
1. TRIGGER THE MAIL OR FAX PACKET TO THE POC FOR RECORDS FIRST.
2. MAKE A FOLLOW-UP CALL TO THE POC WHO WILL GRANT PERMISSION, USING SECTION J: GAINING PERMISSION.


• IF A COURTESY PACKET MUST BE SENT, YOU MUST DO THE FOLLOWING:
1. TRIGGER THE MAIL OR FAX PACKET TO THE POC FOR THE COURTESY PACKET FIRST.
2. TRIGGER THE MAIL OR FAX PACKET TO THE POC FOR RECORDS.

SECTION 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 2010. [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 2010. Much of the information we need is within the billing 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.

• IF PERSON ON THE PHONE IS CONCERNED ABOUT RECEIVING A FAX, EXPLAIN THAT IT IS POSSIBLE TO SEND THE AUTHORIZATION FORMS IN THE MAIL.
  
  
• IF THE PERSON ON THE PHONE STATES THAT THEY ARE NOT THE CORRECT PERSON TO GET THE INFORMATION FROM, ASK THEM TO TRANSFER YOU TO THE CORRECT PERSON AND RESTART THIS SECTION, OR ASK FOR THE NAME AND TELEPHONE NUMBER OF THAT PERSON WE NEED TO SPEAK WITH - ENTER THIS INTO THE CONTACT BLOCK.
  
  
• PRESS NEXT CONTINUE TO THE CONTACT BLOCK

[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 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.

[GO TO CONTACT BLOCK]

PROVIDER VERIFICATION SCREEN  (This sreen is seen before AFs are sent.)

[A5]  CONTROL SYSTEM WILL FLAG IF PROVIDER IS PART OF CONTACT GROUP:

IF CONTACT GROUP................................................ 1 (ASK FOLLOWING QUESTION)
IF NOT A CONTACT GROUP. .................................. 2 (EXIT)

Before we send you the authorization form(s), I’ll need to determine that all of the providers I have listed were in fact associated with this practice during 2010. I’m going to read you a list of providers, and for each one, please tell me if each one was associated with this practice in 2010.

IF A PROVIDER IS NOT ASSOCIATED WITH THIS PRACTICE IN 2010, CHECK THE BOX NEXT TO THEIR NAME. IF NO PROVIDERS ARE REMOVED FROM THE LIST, YOU MUST STILL CLICK SAVE BELOW.