MEDICAL EXPENDITURE PANEL SURVEY
MEDICAL PROVIDER COMPONENT

CONTACT GUIDE
FOR
INSTITUTION PROVIDERS

FOR
REFERENCE YEAR 2016

SECTION MR_A: CALL PROVIDER

MR_A1. Hello, have I reached [PROVIDER]?

PHONE NUMBER: [PROVIDER TELEPHONE NUMBER]

  1. YES = 1
  2. NO, BUT CAN RECORD A NEW NUMBER = 2
  3. NO, NEED TO TRACE THE CASE = 3

[IF MR_A1 = 1 GO TO MR_A2,
IF MR_A1 = 2 GO TO CONTACT BLOCK,
IF MR_A1 = 3 GO TO EXIT SCREEN]

MR_A2. I have [an] authorization form[s] for the release of medical records and would like to speak to the person who can help me with that process.

  1. CONTINUE, THIS PERSON CAN HELP = 1
  2. COLLECT CONTACT INFORMATION FOR SOMEONE ELSE = 2
  3. NO MEDICAL RECORDS DEPARTMENT; UNCLEAR WHO HANDLES RECORDS = 3

[IF MR_A2= 1 GO TO MR_B1,
IF MR_A2=2 GO TO CONTACT BLOCK,
IF MR_A2=3 GO TO EXIT SCREEN]

SECTION 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]

  1. CONTINUE, THIS PERSON CAN HELP = 1
  2. 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?

  1. YES, THIS IS A LONG-TERM CARE FACILITY = 1
  2. 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:

  1. A doctor's office = 1
  2. A publicly-funded clinic = 2
  3. An urgent care center = 3
  4. A home care provider = 4
  5. A hospital – not a long term care unit, such as a Skilled Nursing Facility, or = 5
  6. 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 SCREEN. ONCE YOU EXIT, CODE THE CASE AS "PROVIDER INELIGIBLE"

[GO TO EXIT SCREEN]

MR_B4. At this time, [NUMBER FROM PATIENT LIST] patient[s] identified [PROVIDER] as a source of health care during 2016. [The/Each] patient signed an authorization form allowing us to contact you for information about the CARE THEY received from [PROVIDER] in 2016. 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?

  1. OFFICE MAINTAINS THE INFORMATION = 1
  2. 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?

  1. YES = 1
  2. 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?

  1. YES = 1
  2. 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?

  1. YES = 1
  2. NO = 2

[IF MR_B5 = 1 GO TO CONTACT BLOCK,
IF MR_B5 = 2 GO TO EXIT SCREEN.]

SECTION 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.

  1. CONTINUE, THIS PERSON CAN HELP = 1
  2. COLLECT CONTACT INFORMATION FOR SOMEONE ELSE = 2

[IF MR_C1=1, GO TO MR_C2,
IF MR_C1=2, GO TO CONTACT BLOCK]
[POC NAME] should fill with the name flagged as primary from 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 2016. [The/Each] patient signed an authorization form allowing us to contact you for information about the care they received from [PROVIDER] in 2016.

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?

  1. YES = 1
  2. 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?

  1. YES = 1
  2. NO = 2

[IF MR_C3 = 1 GO TO CONTACT BLOCK,
IF MR_C3 = 2 GO TO EXIT SCREEN.]

SECTION MR_D: CALL MR SERVICE

MR_D1. Have I reached [MEDICAL RECORDS SERVICE]?

PHONE NUMBER: [MEDICAL RECORDS SERVICE TELEPHONE NUMBER]

  1. YES = 1
  2. 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 2016. 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.

  1. CONTINUE = 1
  2. SERVICE DOES NOT MAINTAIN 2016 RECORDS FOR PROVIDER = 2
  3. NOT CLEAR WHO TO SPEAK TO; WRONG NUMBER = 3

[IF MR_D2= 1 GO TO MR_E1,
IF MR_D2=2 OR 3 GO TO EXIT SCREEN]

SECTION 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.

  1. CONTINUE, THIS PERSON CAN HELP = 1
  2. 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 2016.

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?

  1. YES = 1
  2. 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?

  1. YES = 1
  2. NO = 2

[IF MR_E3 = 1 GO TO CONTACT BLOCK,
IF MR_E3 = 2 GO TO EXIT SCREEN]

SECTION 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 2016, we are requesting information about the diagnoses and services, and the names of the physicians who treated each patient in 2016.

PROVIDER WILL RESPOND:

  1. BY PHONE = 1
  2. BY FAX = 2
  3. 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 [30 minutes / 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.]

[GO TO MR_F4]


MR_F4.We are also interested in the charges and the summary of payments for each date of service in 2016.  Can you provide this information?

  1. YES = 1
  2. 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?

  1. YES = 1
  2. 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 2016. Can you provide this information as well?

  1. YES = 1
  2. 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?

  1. YES = 1
  2. NO = 2

[IF MR_F5a=1 GO TO CONTACT BLOCK;
IF MR_F5a=2, GO TO EXIT SCREEN]

SECTION MR_G: VERIFY RECEIPT OF AFS

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

  1. PERSON IS ON THE PHONE = 1
  2. PERSON IS NOT AVAILABLE = 2

[IF MR_G_Intro=1, GO TO MR_G1;
IF MR_G_Intro =2, GO TO APPOINTMENT SCREEN]


MR_G1. Hello, my name is (YOUR NAME). I am calling on behalf of the U.S. Department of Health and Human Services. For quality assurance and training purposes, this call may be monitored. We previously spoke about the MEPS study.

Did you receive the authorization form[s] we [faxed/mailed] to you?

  1. YES, RECEIVED ALL = 1
  2. YES, BUT PROBLEM REPORTED/NEEDS A RE-SEND = 2
  3. 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

  1. WILL COMPLETE BY PHONE NOW = 1
  2. WILL COMPLETE BY PHONE IN THE FUTURE = 2

[IF MR_G2=1 GO TO EXIT SCREEN;
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?

DATE:
R’s TIME: AM/PM
TIME ZONE:

[IF COMPLETE, GO TO EXIT SCREEN]


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 2016 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 2016 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 need a final itemized statement that includes payments and adjustments so that we do not have to call back to obtain this information, but we can use ub04/cms 1500 forms to accompany these final itemized statements.

When will you send us these records?

DATE:

IF DATE IS SELECTED REPEAT THE DATE AND THE DAY OF THE WEEK

OR

(NUMBER OF DAYS/WEEKS)

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 SCREEN

MR_G4_2:
INTERVIEWER: USE THIS SCREEN WHEN PROMPTING FOR RECORDS
We were anticipating receiving (medical records/ medical and billing records) from you by [DATE/CALCULATED DATE FROM MR_G4], but my records show we have not received them. Have you sent the records to us?

  1. YES = 1
  2. 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?

  1. FAX = 1
  2. MAIL HARDCOPIES VIA EXPRESS MAIL = 2
  3. MAIL HARDCOPIES VIA REGULAR MAIL = 3
  4. MAIL CDs VIA EXPRESS MAIL = 4
  5. MAIL CDs VIA REGULAR MAIL = 5
  6. HEALTHPORT = 6
  7. 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:

NEXT WILL ROUTE TO EXIT SCREEN

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:

When will you send us these records?

DATE:

IF DATE IS SELECTED REPEAT THE DATE AND DAY OF THE WEEK

OR

(NUMBER OF DAYS/WEEKS)

IF MR ONLY:
Please send in the complete medical records for all 2016 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 2016 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 need a final itemized statement that includes payments and adjustments so that we do not have to call back to obtain this information, but we can use UB04/CMS 1500 forms to accompany these final itemized statements.

MR_G4_6: Thank you. We will call you back if we do not receive the records by [FILL DATE FROM MR_G4_5 (CALCULATE DATE IF DAYS/WEEKS ENTERED)].

INTERVIEWER: SET A CALL BACK AFTER THE RECORDS ARE EXPECTED SO WE CAN PROMPT AGAIN IF THEY STILL HAVE NOT BEEN RECEIVED.

GO TO EXIT SCREEN

MR_G5. I'm sorry. Let me re-send the authorization form[s] to you.

I need to be sure I have the correct information for the packet. Should I direct it to you?

  1. YES = 1
  2. NO = 2

[IF G5=1, GO TO CONTACT BLOCK,
IF G5=2, GO TO CONTACT BLOCK ]


SECTION 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]
  1. MEDICAL RECORDS SERVICE CONTACT INFO IS CORRECT = 1
  2. 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]?

  1. YES = 1
  2. NO = 2

[IF MR_H2 = 1 GO TO CONTACT BLOCK,
IF MR_H2=2 GO TO EXIT SCREEN]


SECTION 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 2016. Could you please check to see if another medical records service maintained medical records for [PROVIDER(S)] in 2016?

  1. OTHER MEDICAL RECORDS SERVICE MAINTAINED RECORDS = 1
  2. NO OTHER MEDICAL RECORDS SERVICE MAINTAINED RECORDS = 2

[IF MR_I1=1, GO TO CONTACT BLOCK,
IF MR_I1=2, GO TO EXIT SCREEN]


DIVIDER SCREEN
*PATIENT ACCOUNTS SHOULD NOT BE CONTACTED UNTIL

ALL MEDICAL RECORDS EVENT FORMS HAVE BEEN COMPLETED

SECTION PA_A: CALL PROVIDER

PA_A1. Hello, have I reached [PROVIDER]?

PHONE NUMBER: [PROVIDER TELEPHONE NUMBER]

  1. YES = 1
  2. NO, BUT CAN RECORD A NEW NUMBER = 2
  3. 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.

  1. CONTINUE, THIS PERSON CAN HELP = 1
  2. COLLECT CONTACT INFORMATION FOR SOMEONE ELSE = 2
  3. NO BILLING DEPARTMENT; UNCLEAR WHO HANDLES BILLING = 3

[IF PA_A2= 1 GO TO PA_B1,
IF PA_A2=2, GO TO CONTACT BLOCK
IF PA_A2=3 GO TO EXIT SCREEN]


SECTION 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.

  1. CONTINUE, THIS PERSON CAN HELP = 1
  2. 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 2016. [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 2016. 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?

  1. OFFICE MAINTAINS THE INFORMATION = 1
  2. 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?

  1. YES = 1
  2. NO = 2

[IF PA_B2_1 = 1, GO TO PA_C2,
IF PA_B2_1 = 2, GO TO PA_B2a]


PA_B2a. I'll need to collect the name and telephone number for the person in your office who deals with the external billing service.

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?

  1. NO, SEND AUTHORIZATION FORMS TO PA = 1
  2. YES, NO NEED TO SEND AUTHORIZATION FORM(S) TO PA POC = 2

[IF PA_B2b = 1 GO TO PA_B2c;
IF PA_B2b = 2 GO TO PA_B2c]


PA_B2c. [IF PA_B2b=1 FILL "I would like to fax the authorization form[s] to you, along with additional information explaining the study. I need to be sure I have the correct information for the packet. Should I direct it to you?"
[IF PA_B2b=2 FILL "I'll need to fax you some basic information about the study. Should I address the fax to you?"

  1. YES = 1
  2. 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?

  1. YES = 1
  2. NO = 2

[IF PA_B3 = 1 GO TO CONTACT BLOCK,
IF PA_B3 = 2 GO TO EXIT SCREEN.]


SECTION PA_C: IDENTIFY BILLING SERVICE

PA_C1. Hello, my name is (YOUR NAME).

I am calling on behalf of the U.S. Department of Health and Human Services.
We are conducting MEPS which is a study about how people in the United States use and pay for health care.
For quality assurance and training purposes, this call may be monitored.

POC: [POC NAME]

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

  1. CONTINUE, THIS PERSON CAN HELP = 1
  2. 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 2016. [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 2016.

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?

  1. YES = 1
  2. 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?

  1. YES = 1
  2. NO = 2

[IF PA_C3 = 1 GO TO CONTACT BLOCK,
IF PA_C3 = 2 GO TO EXIT SCREEN.]


SECTION PA_D: CALL BILLING SERVICE

PA_D1. Have I reached [BILLING SERVICE]?

PHONE NUMBER: [BILLING SERVICE TELEPHONE NUMBER]

  1. YES = 1
  2. NO = 2

[IF PA_D1 = 1 GO TO PA_D2,
IF PA_D1 = 2 GO TO EXIT SCREEN]


PA_D2. We were referred to you by [PROVIDER] about [NUMBER FROM PATIENT LIST] of their patients who received medical service in 2016. 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.

  1. CONTINUE = 1
  2. SERVICE DOES NOT MAINTAIN 2016 RECORDS FOR PROVIDER = 2
  3. NOT CLEAR WHO TO SPEAK TO; WRONG NUMBER = 3

[IF PA_D2= 1 GO TO PA_E1,
IF PA_D2= 2 OR 3, GO TO EXIT SCREEN]


SECTION PA_E: BILLING SVC: IDENTIFY POC

PA_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.

  1. CONTINUE, THIS PERSON CAN HELP = 1
  2. COLLECT CONTACT INFORMATION FOR SOMEONE ELSE = 2

[IF PA_E1=1, GO TO PA_E2,
IF PA_E1=2, GO TO CONTACT BLOCK]


PA_E2. We were referred to you by [PROVIDER] for information about one or more of (his/her/their) patients. At this time, [NUMBER FROM PATIENT LIST] patient[s] signed an authorization form allowing us to contact you for information about the care they received from [PROVIDER] in 2016. For each date of service in 2016 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?

  1. YES = 1
  2. 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?

  1. YES = 1
  2. NO = 2

[IF PA_E3 = 1 GO TO CONTACT BLOCK,
IF PA_E3 = 2 GO TO EXIT SCREEN]


SECTION 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 2016, we are collecting the amounts charged for services before any adjustments or discounts, and the sources and amounts of payment.

PROVIDER WILL RESPOND:

  1. BY PHONE = 1
  2. BY FAX = 2
  3. 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 [30 minutes / 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 hope you can send the records to our office within two weeks.

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

[GO TO PA_F4 PRELOGIC
PRE_LOGIC FOR PA_F4 & PA_F4a:
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 2016. Can you provide this information as well?

  1. YES = 1
  2. NO = 2

[IF PA_F4=1 GO TO CONTACT BLOCK;
IF PA_F4=2 GO TO PA_F4a.]


PA_F4a. Can you please provide the name and number for whom we should contact to obtain this information?

  1. YES = 1
  2. NO = 2

[IF PA_F4a=1 GO TO CONTACT BLOCK;
IF PA_F4a=2 GO TO EXIT].


SECTION PA_G: VERIFY RECEIPT OF AFS

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

  1. PERSON IS ON THE PHONE = 1
  2. PERSON IS NOT AVAILABLE = 2

[IF PA_G_Intro=1, GO TO PA_G1;
IF PA_G_Intro =2, GO TO APPOINTMENT SCREEN]


PA_G1. Hello, my name is (YOUR NAME). I am calling on behalf of the U.S. Department of Health and Human Services. For quality assurance and training purposes, this call may be monitored. We previously spoke about the MEPS study.

Did you receive the [authorization form[s]/information explaining the study] we [faxed/mailed] to you?

  1. YES, RECEIVED ALL = 1
  2. YES, BUT PROBLEM REPORTED/NEEDS A RE-SEND = 2
  3. 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.

  1. WILL COMPLETE BY PHONE NOW = 1
  2. WILL COMPLETE BY PHONE IN THE FUTURE = 2

[IF PA_G2=1 GO TO EXIT SCREEN;
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?

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

[IF COMPLETE, GO TO EXIT SCREEN]


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 2016 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 2016 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 need a final itemized statement that includes payments and adjustments so that we do not have to call back to obtain this information, but we can use UB04/CMS 1500 forms to accompany these final itemized statements.

When will you send us these records?

DATE:______________

IF DATE IS SELECTED REPEAT THE DATE AND DAY OF THE WEEK

OR

____________(NUMBER OF DAYS/WEEKS)

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’.

PA_G4_2

INTERVIEWER: USE THIS SCREEN WHEN PROMPTING FOR RECORDS

We were anticipating receiving (IF PA ONLY: billing and payment records / IF MR & PA: medical records and billing and payment records) from you by [DATE/CALCULATED DATE FROM PA_G4], but my records show we have not received them. Have you sent the records to us?

  1. YES = 1
  2. 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?

  1. FAX (1)
  2. MAIL HARDCOPIES VIA EXPRESS MAIL (2)
  3. MAIL HARDCOPIES VIA REGULAR MAIL (3)
  4. MAIL CDs VIA EXPRESS MAIL (4)
  5. MAIL CDs VIA REGULAR MAIL (5)
  6. HEALTHPORT (6)
  7. 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:

NEXT WILL ROUTE TO EXIT SCREEN

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:

When will you send us these records?

DATE:______________

IF DATE IS SELECTED REPEAT THE DATE AND DAY OF THE WEEK

OR

____________(NUMBER OF DAYS/WEEKS)

IF PA ONLY: Please send in the final billing records for all 2016 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 2016 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 need a final itemized statement that includes payments and adjustments so that we do not have to call back to obtain this information, but we can use UB04/CMS 1500 forms to accompany these final itemized statements.

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 STILL HAVE NOT BEEN RECEIVED.

GO TO EXIT SCREEN

PA_G5. I'm sorry. Let me re-send the [authorization form[s]/information explaining the study] to you. I need to be sure I have the correct information for the packet. Should I direct it to you?

  1. YES = 1
  2. NO = 2

[IF PA_G5=1, GO TO CONTACT BLOCK,
IF PA_G5=2, GO TO CONTACT BLOCK, ]


SECTION 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]

  1. BILLING SERVICE CONTACT INFO IS CORRECT = 1
  2. 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]?

  1. YES = 1
  2. NO = 2

[IF PA_H2 = 1 GO TO CONTACT BLOCK,
IF PA_H2=2 GO TO EXIT SCREEN.]


SECTION 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 2016. Could you please check to see if another billing service maintained billing and payment records for [PROVIDER(S)] in 2016?

  1. OTHER BILLING SERVICE MAINTAINED RECORDS = 1
  2. NO OTHER BILLING SERVICE MAINTAINED RECORDS = 2

[IF PA_I1=1, GO TO CONTACT BLOCK;
IF PA_I1=2, GO TO EXIT SCREEN]


SECTION AO_A: PROVIDER/AO CONTACT

AO_A1. Have I reached [POC NAME]?

PHONE NUMBER: [POC TELEPHONE NUMBER]

  1. YES = 1
  2. NO, BUT CAN RECORD A NEW NUMBER = 2
  3. NO, NEED TO TRACE THE CASE = 3

[IF AO_A1 = 1 GO TO AO_A2,
IF AO_A1 = 2 GO TO CONTACT BLOCK,
IF AO_A1 = 3 GO TO AO EXIT]


AO_A2.

IF AO POC WAS PROVIDED BY MEDICAL RECORDS OR PATIENT ACCOUNTS:
May I please speak to [POC NAME]?

IF NO AO POC WAS PROVIDED BY MEDICAL RECORDS OR PATIENT ACCOUNTS:
“Can I please speak to someone in the administrative office who can help me with contacting/locating information for providers?”

  1. CONTINUE, THIS PERSON CAN HELP = 1
  2. COLLECT CONTACT INFORMATION FOR SOMEONE ELSE = 2
  3. UNCLEAR WHO TO SPEAK TO = 3

[IF AO_A2= 1 GO TO AO_A3,
IF AO_A2=2, GO TO CONTACT BLOCK,
IF AO_A2=3, GO TO EXIT SCREEN]


AO_A3. 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]

  1. CONTINUE, THIS PERSON CAN HELP = 1
  2. 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.

  1. WILL COMPLETE BY PHONE NOW = 1
  2. 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?

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

[IF COMPLETE, GO TO EXIT SCREEN]


AO_A5 NEED THE ABILITY TO PULL UP THE LIST OF PROVIDERS THAT WAS COLLECTED IN MR SECTION

GO TO SBD SUBROUTINE [SBD_CGINTRO]



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?

  1. BILLS SEPARATELY = 1
  2. CHARGES INCLUDED IN FACILITY BILL = 2
  3. BILLING ARRANGEMENT VARIES (SPECIFY) = 3
  4. DON'T KNOW = 4

SBD_CG7. What is the business practice phone number and location for [FILL]?

[DK/REF/RETRIEVABLE - CONTINUE TO SBD_CG8A]


SBD_CG8b. Does this physician use a billing service or have billing contact information that is different than his or her business practice location?

  1. YES = 1
  2. NO = 2

[IF SBD_CG8b = 1 (YES), GO TO SBD_CG9;
IF SBD_CG8b = 2 (NO), GO TO SBD_CG10;
DK/REF/RETRIEVABLE - GO TO SBD_CG10]


SBD_CG9. What is the billing contact information?

[DK/REF/RETRIEVABLE - CONTINUE TO SBD_CG10]


SBD_CG10. RECORD ANY NOTES AO GIVES ABOUT [PHYSICIAN NAME]


GENERAL NOTES:


[DK/REF/RETRIEVABLE - DONE WITH FORM]

Clicking the hyperlink “Finalize” will open a brief survey, similar to the Disavowal hyperlink in Patient Listing Screen of the CMS.

How are you finalizing this SBD? SELECT ONE.

  1. Done with this SBD- contacting information collected or confirmed does not bill separately
  2. Done with this SBD - unable to collect contacting information
  3. Still working to obtain contact information for this SBD

[GO BACK TO SBD GRID]


[AFTER ALL SBDS HAVE BEEN UPDATED, SELECTING NEXT WILL TAKE YOU TO SBD_CG11.]


SBD_CG11. HAVE YOU OBTAINED CONTACT INFORMATION FOR ALL PROVIDERS/SBDs IN THE LIST?

  1. YES, OBTAINED ALL AVAILABLE CONTACT INFORMATION FOR ALL SBDs LISTED = 1
  2. NO, STILL WORKING ON GETTING CONTACT INFORMATION = 2

[IF SBD_CG11 = 1 GO TO EXIT SCREEN;
IF SBD_CG11 = 2 GO TO SBD_CG12.]


SBD_CG12. Who would be able to help me with the information for the remaining providers?

  1. ADDITIONAL AO POC PROVIDED = 1
  2. DK; NO ADDITIONAL AO POC PROVIDED = 2

[IF SBD_CG12 = 1 GO TO CONTACT BLOCK,
OR IF SBD_CG12 = 2 GO TO EXIT SCREEN]


SECTION J: GAINING PERMISSION: TALKING POINTS

INTRODUCTION:

May I please speak to [POC NAME]?

Hello, my name is (YOUR NAME).

I am calling on behalf of the U.S. Department of Health and Human Services. We are conducting MEPS which is a study about how people in the United States use and pay for health care. For quality assurance and training purposes, this call may be monitored.

I recently spoke with {POC YOU ARE WORKING WITH FOR DATA COLLECTION} about the study. I explained that at this time, [NUMBER FROM PATIENT LIST] patient[s] identified [PROVIDER] as a source of health care during 2016. [The/Each] patient signed an authorization form allowing us to contact you for information about the diagnoses and services provided by [PROVIDER] in 2016. 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 forms[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?

[NEXT TAKES USER TO CONTACT BLOCK]


BRANCH

TYPICAL CONTACT SEQUENCE BY SECTION:

INTERNAL BILLING: A, B, Contact Block, F, end call
EXTERNAL BILLING SERVICE: Call provider, A, B, C, Contact Block, end call.
Call billing service: D, E, edit Contact Block, end call

VERIFY AFs WERE RECEIVED: Go to G

CLICK ON YOUR NEXT STEP

  1. 1. MR IDENTIFY A POC AT THIS PROVIDER'S OFFICE (SECTION MR_B)
  2. 2. MR IDENTIFY A POC WHO WORKS WITH EXTERNAL BILLING SERVICE (SECTION MR_C)
  3. 3. MR - CALL THE EXTERNAL BILLING SERVICE (SECTION MR_D)
  4. 4. MR VERIFY AUTHORIZATION FORMS WERE RECEIVED (SECTION MR_G)
  5. 5. PA IDENTIFY A POC AT THIS PROVIDER'S OFFICE (SECTION PA_B )
  6. 6. PA IDENTIFY A POC WHO WORKS WITH EXTERNAL BILLING SERVICE (SECTION PA_C)
  7. 7. PA CALL THE EXTERNAL BILLING SERVICE (SECTION PA_D)
  8. 8. PA VERIFY AUTHORIZATION FORMS WERE RECEIVED (SECTION PA_G)

For first set of radio buttons (MR section)
IF FIRST RADIO BUTTON IS SELECTED, GO TO MR_B1.
IF SECOND RADIO BUTTON IS SELECTED, GO TO MR_C1.
IF THIRD RADIO BUTTON IS SELECTED, GO TO MR_D1.
IF FOURTH RADIO BUTTON IS SELECTED, GO TO MR_G1

For second set of radio buttons (PA section)
IF FIRST RADIO BUTTON IS SELECTED, GO TO PA_B1.
IF SECOND RADIO BUTTON IS SELECTED, GO TO PA_C1.
IF THIRD RADIO BUTTON IS SELECTED, GO TO PA_D1.
IF FOURTH RADIO BUTTON IS SELECTED, GO TO PA_G1


CONTACT BLOCK

CONTACT FIELDS

PROVIDER NAME:
MEDICAL RECORDS/BILLING SERVICE NAME:
POC FIRST NAME:
POC LAST NAME:
PHONE:
EXT:
TIME ZONE:
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

CB2a. WHICH SECTIONS OF THE CONTACT GUIDE APPLY TO THIS POC?

  1. MEDICAL RECORDS
  2. PATIENT ACCOUNTS
  3. ADMINISTRATIVE OFFICE
  4. MEDICAL RECORDS AND PATIENT ACCOUNTS
  5. MEDICAL RECORDS AND ADMINISTRATIVE OFFICE
  6. PATIENT ACCOUNTS AND ADMINISTRATIVE OFFICE
  7. MEDICAL RECORDS, PATIENT ACCOUNTS AND ADMINISTRATIVE OFFICE POC

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


CB2. WHAT TYPE OF POC IS THIS PERSON?

  1. PROVIDER LEVEL GATEKEEPER
  2. HANDLES RELEASE OF IN-HOUSE RECORDS
  3. DEALS WITH IN-HOUSE RECORDS FOR MR
  4. DEALS WITH IN-HOUSE RECORDS FOR PA
  5. DEALS WITH MEDICAL RECORDS SERVICE
  6. DEALS WITH EXTERNAL BILLING SERVICE
  7. MEDICAL RECORDS SERVICE GATEKEEPER
  8. EXTERNAL BILLING SERVICE GATEKEEPER
  9. HANDLES RELEASE OF RECORDS FOR MEDICAL RECORDS SERVICE
  10. HANDLES RELEASE OF RECORDS FOR EXTERNAL BILLING SERVICE
  11. ADMINISTRATIVE OFFICE POC
  12. HANDLES RELEASE OF IN-HOUSE RECORDS & IS ADMINISTRATIVE OFFICE POC
  13. COURTESY PACKET RECIPIENT
  14. PERMISSION PACKET RECIPIENT
  15. POC FOR REMAINING PROVIDERS (SBDs)
  16. NEW/UPDATED NAME FOR PROVIDER

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

CALLBACK/APPOINTMENT SCREEN

Can you please provide me with a better time to call back in order to reach him/her?

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

[ALL GO TO EXIT FROM HERE]


EXIT SCREEN

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

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

IF POC RECEIVED AUTHORIZATION FORMS AND CAN REPORT DATA BY PHONE NOW, ENTER EVENT CODE 441: AFs Received-Ready for 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 TO CMS BY PRESSING FINISH, BREAK-OFF SHOULD BE A SEPARATE FUNCTION.]

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 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].]