Blank EMStart Questionnaire

EMS AGENCY DATA

1. What is your EMS Service Legal Name (as it appears on your IRS documents)?:*

2. What is your "Doing Business As" (DBA) Name?:*

EMS|MC will use this name for all reporting, invoicing, and applications.

3. Please attach your official EMS agency logo below:

Drop files here or

Max. file size: 50 MB.

4. What is the physical address of your EMS agency?:*

Street Address Address Line 2 City State ZIP Code

5. What county or counties does your EMS agency operate in?:*

6. What is the mailing address of your EMS agency (if different from physical address)?:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

7. Please list all of your different practicing locations:*

Station:	Address:	Telephone #:	Date Established:

A practicing location is defined as anything leased, owned, or provided by an entity to operate out of.

8. What is the date that your EMS service was first established (mm/dd/yyyy)?:*

If month and date are unknown, please provide the year.

8.a. Please attach a copy of the state ambulance license below:

Max. file size: 50 MB.

8.b. Please attach copies of DMV registration cards or titles below:

Drop files here or

Max. file size: 50 MB.

8.c. Please attach your IRS Verification Letter (147-C):

Max. file size: 50 MB.

9. Is your EMS agency tax exempt?:*

Yes
No

9.a. If tax exempt, please provide a copy of your "Tax Exemption Certificate":

Max. file size: 50 MB.

10. Is your EMS agency incorporated?:

Yes
No

10.a. Please provide the date of incorporation for your EMS agency (mm/dd/yyy):

10.b. Please attach a copy of your Articles of Incorporation below:

Max. file size: 50 MB.

Not applicable for government agencies

11. Is your EMS agency privately owned?:

Yes
No

11.a. Please list the owners and their ownership percentage:

Name:	Ownership Percentage:

12. Date first rendered services to Medicare patients:

13. Do you currently bill for services?:

Yes
No

13.a. Is billing currently outsourced?:

Yes
No

13.b. Name of current billing agency:

13.c. Billing Agency Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

13.d. Billing Agency Contact:

Name:	Telephone #:	Email Address:

13.e. What is the last date of service the current billing agency will bill?*

13.f. What is the wind down period for the current billing agency?*

13.g. What is your current patient invoice billing cycle? Please note the number of statements and frequency:

14. Which clearinghouse is used for claims and remits?:

ZirMed
TriZetto
Availity

15. What is your desired billing start/go-live date with EMS|MC?:*

16. Fiscal Year Start (mm/dd):*

17. Approximate # of Transports per year:*

Please enter a number greater than or equal to 0.

This estimation should be based on DOS rather than billing period.

18. Approximate # of Billable Transports per year:*

Please enter a number greater than or equal to 0.

This estimation should be based on DOS rather than billing period.

19. EMS|MC recommends your charges be at least 150% of the Medicare allowable. Are you currently billing at or above this rate?:*

Yes
No

19.a. Do you want to update your current rates to be 150% of the allowed amount?:

Yes
No

20. Do you have any ordinances in place that allow for auto updates of these charges as the Medicare rates change? Please explain:

21. Do you provide scheduled/non-emergency transports in addition to 911/emergency transports?:*

Yes
No

21.a. Do you provide wheelchair transports?*

Yes
No
Other

22. Highest Level of Service Provided:*

23. Does your EMS agency accept Pre-Payments?*

Yes
No

23.a. Will you provide patients with the Notice of Privacy Practices (NPP) or would you like EMS|MC to?:*

We will provide it
We want EMS|MC to provide it (there will be a fee for this service)

23.b. Would you like EMSIMC to add our Patient Satisfaction Survey link on patient invoices?*

Yes (EMS|MC will provide at no additional cost to client)
No

EMS AGENCY CONTACTS

Primary Contact

24. Primary Contact Name:*

Title:

Address (if different from above):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Numbers and Email:

Work Phone:	Cell Phone:	Fax Number:	Email:

Primary Billing/Documentation Contact

25. Billing/Documentation Contact Name:*

Title:

Address (if different from above):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Numbers and Email:

Work Phone:	Cell Phone:	Fax Number:	Email:

Primary Financial Contact

26. Financial Contact Name:*

Title:

Address (if different from above):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Numbers and Email:

Work Phone:	Cell Phone:	Fax Number:	Email:

27. Please List Any Additional Contacts:

Name	Title	Address	Telephone	Cell	Email

If needed, please provide notes below.

28. Who is the current authorized signer on your Medicare enrollment?:*

Please refer to last submitted 855B application; we will be asking for a copy of this further into the deployment process.

Does your EMS Agency have access to CMS's Provider Enrollment, Chain, and Ownership System (PECOS) portal?*

Yes
No
Unknown

PECOS is the online Medicare enrollment management system.

DEPOSIT PROCESS

29. What is the name of your EMS agency's financial institution?:

30. What is the name that appears on your EMS agency's bank account?:

31. What is the address of your EMS agency's financial institution?:

Street Address Address Line 2 City State ZIP Code

32. Is your EMS agency's bank account shared?:

Yes
No

E.g. Health Department

33. Does your EMS agency possess an EMS-only bank account?:

Yes
No

33.a. Do you use lockbox services at your bank to streamline deposit processing and posting of remittances?

Yes
No
Unknown

34. Does your EMS agency's financial institution have branches in North Carolina?:

Yes
No

These banks include but are not limited to: • Bank of America • Bank of the Ozarks • BB&T • Capital Bank (new) • Fidelity • First Bank • First Citizens • PNC • Suntrust • Wells Fargo • Pinnacle Financial Partners

34.a. Please list a contact at your EMS agency that we can request deposit slips from:

Name	Telephone Number	Email

35. Are you considering transitioning banks or bank accounts for your EMS agency?:*

Yes
No

PAYER INFORMATION

36. Please provide your Employee Identification Number (EIN) / Tax ID:*

37. Is this Tax ID shared with another agency who would file healthcare claims?:*

E.g. Health Department

38. Does your EMS agency possess a National Provider Identification (NPI) number?:

Yes
No

38.a. Please provide your NPI number:*

39. Please provide provider ID numbers and effective dates for the payers listed in the description:

Payer:	ID Number:	Effective Dates:

Medicare, Medicaid, Railroad Medicare, BlueCross BlueShield, Aetna, Humana, Tricare, Department of Labor, and United Health Care

40. Please attach additional provider ID numbers and effective dates as a document below:

Drop files here or

Max. file size: 50 MB.

41. What percentage of your payer mix is Medicare and Medicaid?:

Medicare	Medicaid

42. Do you regularly transport patients who reside in another state?:*

Yes
No

42.a. Which other states do you transport patients in?

43. Are you contracted (a participating provider) with any commercial insurance companies?*

Yes
No

43.a. Which commercial insurance companies are you contracted with? Please list the effective dates for each one:*

Name:	Effective Date:

43.b. Please upload a copy of the contract(s) below:

Drop files here or

Max. file size: 50 MB.

44. Please list all payers from which you have received Electronic Fund Transfers (EFTs):

Examples include: Medicare, Medicaid, BCBS/Anthem, Aetna, UHC. If none, please list "none".

45. Please list all payers from which you have received Electronic Remits:

Examples include: Medicare, Medicaid, BCBS/Anthem, Aetna, UHC. If none, please list "none".

46. Please list all payers to whom you have access to websites for remits:

Examples include: Medicare, Medicaid, BCBS/Anthem, Aetna, UHC. If none, please list "none".

If needed, please provide notes below.

ePCR Information

47. Who is your current ePCR vendor?*

48. Is hospital data exchange (HDE) included with your ePCR?*

Yes
No

48.a. If a hospital data exchange (HDE) is included with your ePCR, please provide the details below:

49. If you have any plans to transition ePCR vendors in the near future, please provide the details below:

50. What is the "Quality Assurance" (Q/A) status that trips will be marked with in your ePCR when they are ready to be billed?:*

E.g. "Ready to be billed", or "QM approved"

51. How often does your EMS Agency Q/A trips?:

52. Who is responsible for the Q/A of trips?:*

Is there a dedicated role assigned to Q/A trips?

53. Do you need reporting by area, profit center, zone, and/or area resident/subscriber information?:*

Yes
No

53.a. Please list these reporting groups as they appear in your ePCR:

Agency Name:	Address:	City:	State:	Zip Code:	Contact Name:	Contact Phone Number:	Email:

Punctuation, spacing, and upper/lower case are important.

54. Does your agency transport to/from prisons/correctional facilities?:

Yes
No

54.a. Please provide a list of the prisons/correctional facilities your agency that your agency transports to/from:

Name of Correctional Facility:	Privately Owned or Government Funded:	Address:	City:	State:	Zip Code:

CUSTOMER SERVICE POLICIES

55. Will EMS|MC be processing credit card payments on your behalf?*

Yes
No

56. A $5 convenience fee will be charged to the patient per transaction, unless your ordinance/county specifically excludes this fee. Does your ordinance/county exclude this fee?:

Yes
No

57. How would you like to be reimbursed for credit card and ACH payments?*

Line item credit on monthly invoice (standard process)
Separate check (alternative process)

58. Do you offer balance reductions/rate discounts to any other third parties? If so, please describe below:*

59. Do you review financial hardship discount/charity care requests from patients?:*

Yes
No

59.a. To whom would you like us to send these requests?:

Name	Title	Phone Number	Email

60. Do you accept a general letter of hardship from patients or do you have a specific form you would like to use?:

We accept a general letter
We have a specific form

60.a. If you have a specific hardship form, please attach a copy of your form or explain the information you require in the patient's letter.

Max. file size: 50 MB.

61. To whom should we send patient disputes regarding the provider service at the time of transport/care?:

Name	Title	Telephone Number	Email

62. Do you charge a returned check fee?:*

Yes
No

62.a. What is your returned check fee amount?:

Please enter a number greater than or equal to 0.

63. EMS|MC'standard policy to allow patients to set up payment plans with a minimum payment of $25/month, with payment due every 30 days. If you have a different time payment plan policy, please explain below:*

64. What is your county's emergency services phone number?:

LEGAL AND ESTATES

65. Do you require proof of death for deceased patients?:*

No
Yes, we require a death certificate
Yes, we accept a death certificate, obituary, and/or funeral program

66. If a patient dies after transport, would you like to pursue the estate or write off the remaining balance after filing to insurance?*

Write off the remaining balance
Pursue the patient's estate

67. Will you accept a balance reduction by the attorney on behalf of the patient?*

68. Will EMS|MC handle records requests from attorneys?:*

Yes (EMS|MC will fulfill requests via ChartSwap at no additional cost to client)
No (Client will fulfill records requests from attorneys)

If needed, please provide notes below.

BILLING PROCEDURES

69. Does your EMS agency have an Area Residence Policy or any in-county billing procedures?:*

Yes
No

69.a. What are the determining factors for area residence status?:

E.g. zip code, county residence, etc.

69.b. Are area resident patients responsible for paying a deductible?:

Yes
No

69.c. What is the process for insurance payments made directly to a resident patient?

69.d. What is the process for billing non-covered services?:

69.e. Please provide any additional information as needed:

Drop files here or

Max. file size: 50 MB.

70. Does your EMS agency have a Membership/Subscription program?:*

Yes
No

70.a. Please explain the Membership/Subscription program; include information about pricing, effective dates, and enrollment period, as needed:*

70.b. Attach copies of the Membership/Subscription program brochures/flyers, registration form and renewal letters:

Drop files here or

Max. file size: 50 MB.

71. Do you determine ALS procedure based on dispatch protocol/EMD card or based on services rendered?*

Dispatch Protocol
Services Rendered

72. If dispatch protocol/EMD card is used, please define your EMS agency's below:

e.g. Alpha, Bravo, Charlie, etc.

73. If dispatch protocol/EMD card is used, please attach a copy of them below:

Drop files here or

Max. file size: 50 MB.

74. Does your EMS agency have any contracts with facilities?:*

Yes
No

E.g. Prison, County/City Jail, Hospice, Nursing Facility, Hospital, etc.

74.a With what sort of facilities does your EMS agency have contracts?:

74.a.1. Please list the hospice facilities below.*

Name	Address	Contracted Rate

If none, note "none" or "n/a"

74.a.2. Other:

74.b. Please attach a copy of the agreement(s), pricing, etc.:

Drop files here or

Max. file size: 50 MB.

74.c. Do the facility contracts include language for PCS/medical necessity form requirements?*

Yes
No

74.d. Please provide instructions for special invoicing and balance billing patients from these facilities:*

E.g. Prison, County/City Jail, Hospice, Nursing Facility, Hospital, etc.

75. In the case that a hospice patient is billed, the hospice facility denies the claim, and the patient does not have insurance: Do you want EMS|MC to balance bill the patient or write off the remaining balance?*

Balance bill
Write off

76. Please explain your policy for billing indigent/homeless patients: a. Will you bill insurance? b. Will you balance bill? c. If you use collections, do you wish to send these patients to collections?:*

77. Please list any known homeless facilities in the area:

Name	Address

78. What is the greatest distance you would expect to travel to either pick up or drop off a patient?:*

EMS|MC will add a mileage cap to our billing system to flag unusually high mileage.

79. Do you have contracts with other EMS agencies (i.e. paramedic intercept, mutual aid)?:*

Yes
No

79.a. Please explain the nature of these agreement(s):*

79.b. If available, please attach copy of agreement(s) below:

Drop files here or

Max. file size: 50 MB.

80. Do you have a special policy for billing employees or other public safety personnel?:*

Yes
No

80.a. Does this policy extend to off-duty personnel?:*

80.b. Besides medics, who does this policy extend to?:*

E.g. members of public safety, city employees, county employees?

80.c. Where will you notate this policy on the PCR/ACR?:*

81. How do you collect Patient Signature Authorization forms?:*

Attachment
Electronic Capture

82. How do you collect the Medical Record Author's Signature forms?:*

Attachment
Electronic Capture

83. Please explain your policy for billing non-emergency transports, include any policy relating to prior authorization documentation:

MS|MC requires medical necessity forms such as a Physician Certification Statement (PCS) or EMTALA form to bill scheduled transports

84. Please explain your billing policy for "Deceased on Arrival" (DOA):

Patient deceased prior to dispatch:	Patient pronounced deceased at the scene:	Patient pronounced deceased enroute or at hospital:

85. Please explain your "Treatment No Transport" (TNT) billing policy:

Be specific: Bill as BLS-E? Cancel the trip? Charge a different rate based on services rendered (i.e. whether it is only a lift assist response, MVA response, or certain supplies are used)?

85.a. Please explain your 'Special Events' policy:

Be specific: List locations, special rates or any other special billing policies.

88. Please provide your current rates for the following (please enter 0 if not applicable):

BLS Non-emergency:

BLS Emergency:

ALS Non-emergency:

ALS Emergency:

What percentage of trips performed are ALS Emergency?*

ALS 2:

Specialty Care Transport:

Treatment No Transport (TNT):*

Deceased On Arrival (DOA):*

Mileage:

87. Do you itemize for supplies, oxygen, etc?:

Yes
No

87.a. Please upload a detailed list via separate sheet:

Max. file size: 50 MB.

88. Do you provide air medical services?:*

Yes
No

88.a. Please provide a copy of your 135 license certification:

Max. file size: 50 MB.

Air Carrier/Air Operator Certificate

88.b. Please provide a list of referring facilities if there are any other than yourself:

88.c. Please provide a list of frequently used landing zones:

88.d. Are separate ePCRs and PCRs used for air and ground? Please explain.:

88.e. Do you bill Segway mileage or straight line mileage? Please explain:

88.f. Please provide air protocols below:

88.g. Alternatively, please attach copies of your air protocols:

Max. file size: 50 MB.

88.h. Please provide your air rates below:

88.i. Alternatively, please attach a list of your air rates:

Max. file size: 50 MB.

89. If your out-of-county rates differ from those above, please list below. If they are the same, please, list "None":*

90. If any additional billing rates apply, please list below. If none, list "None":*

BILLING PROCESS CONTINUED

91. Is your county mandated to provide ALS services?:

Yes
No

92. Are all ambulances staffed at the paramedic level?:

Yes
No

93. Does your EMS agency have any paramedics with critical care credentialing?:

Yes
No

93.a. Please provide a list of their names below:

Name

94. Please attach an Excel spreadsheet with the names, training level (basic, intermediate, paramedic), license # and email addresses of all staff members:

Max. file size: 50 MB.

94.a. Do you have employees located outside the US?*

Yes
No

94.b. Please list the non-US country and IT Department contacts:*

Name of Country	IT Department Contact Name	IT Department Phone Number	IT Department E-mail Address

95. Do you want all crew members to be registered for EMS|MC's EMScholar documentation training website?:

Yes
No

96. Do your crew members document based on a certain narrative preference (i.e. SOAP, ACHART, etc.)?:

Yes
No

96.a. Please explain the narrative preference:

97. Do your crew members collect this information? Please select "Yes" or "No" for each:

97.a. Whether service is covered by MVA or Worker's Comp?

Yes
No

97.b. Insurance information?

Yes
No

97.c. Social Security Number?

Yes
No

97.d. Area Residence status (if applicable)?

Yes
No

97.e.. Annual Membership/Subscription status (if applicable)?

Yes
No

97.f. OPUS # (North Carolina Correctional Facility Inmate Number) ?

Yes
No

97.g. Medical Record Documentation/Number?

Yes
No

97.h. Out-of-county mileage?

Yes
No

98. Will EMS|MC bill for any other type of transport or service? If so, please explain:

E.g. wheelchair transports, etc.

FACILITY AND HOSPITAL INFORMATION

99. Please supply a list of the following facilities, if applicable:

99.a. Hospitals that your EMS agency transports to:

Hospital Name	Estimated Annual Volume	Estimated Annual %	Hospital Address	Contact Name	Contact Number	Contact Email

99.b. Nursing facilities that your EMS agency transports to:

Facility Name	Facility Address	Contact Name	Contact Number	Contact Email

100. Do you provide emergency medical services in North Carolina?:

Yes
No

100.a. If you provide EMS services in North Carolina, please list your out-of-county mileage to frequented facilities:

Please list the facility and its out of county mileage

100.b. If needed, please provide notes below.

COLLECTIONS, DEBT SETOFF (State Tax Garnishment), AND WAGE GARNISHMENT INFORMATION

101. Do you use collections?:*

Yes, we use collections in-house
Yes, we use an outside collection agency
No

101.a. Is your EMS agency interested in receiving Collection Agency proposals?*

Yes
No

101.b. What collections agency?

Agency Name:	Agency Address:	Contact Name:	Contact Number:	Contact Email:

101.c. Will EMS|MC provide the monthly collection file to you or to the collection agency?

Provide to us
Provide to collections agency

101.d. To whom should we send the collection file:?

Name	Title	Phone Number	Email

101.e. If provided to the collection agency, do you require time to review beforehand?:

Yes
No

101.f. Who will be our contact(s) for the collections report?:

Name	Title	Phone Number	Email

101.g. What is the minimum amount to be written off and not sent to collections?:*

101.h. Describe your collection agency settlement guidelines. If you do not have settlement guidelines, type N/A.*

101.i. Please attach a copy of your collection agency contract

Drop files here or

Max. file size: 50 MB.

102. Do you currently participate in the state’s tax garnishment/debt set off program?:

Yes
No

102.a. Will EMS|MC be preparing your tax garnishment/debt set off file?:

Yes
No

102.b. Who will be our contact(s) for the tax garnishment/debt set off report?:

Name	Title	Phone Number	Email

102.c. How often do you submit your file to the state?:

Annually
Quarterly

102.d. Do you want EMSIMC to process the tax garnishment/debt set off letters?

Yes
No

102.e. How often do you submit tax garnishment/debt set off letters?

Once a Quarter (4 submissions a year)
Twice a Year (2 submissions a year)

102.f. Do you want EMSIMC to upload the final tax garnishment/debt set off file to the State?

Yes
No

102.g. What is your 'agency code' for tax garnishment/debt set off ?

103. Do you currently participate in a wage garnishment program?:

Yes
No

103.a. Who will be our contact(s) for the wage garnishment report?:

Name	Title	Phone Number	Email

104. Would you like information (best practices) on any of these programs?:

Hold down the Ctrl key to select multiple choices.

COLLECTIONS, DEBT SETOFF (State Tax Garnishment), AND WAGE GARNISHMENT INFORMATION

105. Will you accept monthly payments?:

Yes
No

105.a. What is the minimum payment amount you will accept?:

106. Do you bill patients outside the area (counties) for outstanding balance after insurance pays?:

Yes
No

106.a. Do you use collections for their outstanding debt?:

Yes
No

If no, we will collect insurance payments and take no further action. The rest will be written off.

106.b. If needed, please provide notes below.

EMS|MC REPORTING INFORMATION

107. Please list the name and email of the person(s) to receive the "ACR Return to Provider" report:

Name	Email

ACR Return to Provider = This report provides feedback on patient call reports and highlights missing information so that better documentation practices can be utilized.

108. Please list the name and email of the person(s) to receive the "ACR Return to Provider" report as a daily email:

Name	Email

ACR Return to Provider = This report provides feedback on patient call reports and highlights missing information so that better documentation practices can be utilized.

109. Please list the name and email of the person(s) to receive the Constant Contact:

Name	Email

Constant Contact = This is the main line for your EMS agency to receive global alerts and notifications from EMS|MC.

110. Please list the name and email of the person(s) to receive the Import Confirmation Report:

Name	Email

Import Confirmation Report = This report shows the number of trips imported into our system.

111. Please list the name and email of the person(s) to receive the Missing Signature Report:

Name	Email

Missing Signature Report = This report identifies trips that are missing signatures so that inaccurate documentation habits can be corrected.

112. Please list the name and email of the person(s) to receive the Month End Report:

Name	Email

Month End Report = This report is a financial review of your EMS agency's account at EMS|MC.

113. Please list the name and email of the person(s) to receive the Payments Summary Report:

Name	Email

Payments Summary Report = This report is a deposit workbooks that tracks payments made between EMS|MC and your EMS agency.

114. Please list the name and email of the person(s) to receive the Refunds Report:

Name	Email

Refunds Report = This report summarizes the refunds that have been issued to payers, patients, or other recipients.

If needed, please provide notes below.

FORM SUBMISSION

115. Please list an email address you would like a copy of this completed form sent to after submitting:*

Please list only one email address.

116. One a scale of zero(0) to ten(10), how satisfied are you with the EMStart Questionnaire?*

1-lowest satisfaction, 10-highest satisfaction

117. Please let us know which areas of the EMStart Questionnaire should be prioritized for improvement:*

118. Please provide any additional feedback that pertains to the questions above or your experience with the EMStart Questionnaire (what did you like/dislike?):*

EMS AGENCY DATA

EMS AGENCY CONTACTS

Primary Contact

Primary Billing/Documentation Contact

DEPOSIT PROCESS

PAYER INFORMATION

ePCR Information

CUSTOMER SERVICE POLICIES

LEGAL AND ESTATES

BILLING PROCEDURES

FACILITY AND HOSPITAL INFORMATION

COLLECTIONS, DEBT SETOFF (State Tax Garnishment), AND WAGE GARNISHMENT INFORMATION

EMS|MC REPORTING INFORMATION

FORM SUBMISSION

END OF FORM

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