EMStart Questionnaire Hannah Test

EMS AGENCY DATA

EMS Service Legal Name (as it appears on your IRS documents):*

Doing Business As:*

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

Please attach your official EMS agency logo.

Drop files here or

Physical address:*

Street Address Address Line 2 City State ZIP Code

County/Counties:*

Mailing Address (if different from physical address):

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

Please list all of your different practicing locations, including telephone number/address/date established (practicing location is defined as anything leased, owned, or provided by an entity to operate out of).*

Date EMS service first established (Please list the month, date, and year if known. If not, please list year.):

Is your EMS agency tax exempt?*

Yes
No

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

Is your EMS agency incorporated?

Yes
No

Date of Incorporation

Is your EMS agency privately owned?

Yes
No

Please list the owners and their ownership percentage

Date first rendered services to Medicare patients:

Do you currently bill for services?

Yes
No

Which clearinghouse is used for claims and remits?

ZirMed
TriZetto
Availity

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

Is billing currently outsourced?

Yes
No

Name of current billing agency:

Billing Agency Address

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

Billing Agency Contact

Billing Agency Phone

Fiscal Year Start (mm/dd)*

Approximate # of Transports per year:*

Please enter a number greater than or equal to 0.

Approximate # of Billable Transports per year:*

Please enter a number greater than or equal to 0.

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

Yes
No

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

Yes
No

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

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

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

Yes
No

Highest Level of Service Provided:*

BLS
ALS
ALS 2
Specialty Care

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)

If needed, please provide notes below.

Primary Agency Contact

EMS AGENCY CONTACTS

Name:*

Title:

Address (if different from above):

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

Work Phone:

Cell:

Fax:

Email:

Primary Billing/Documentation Contact

Name:*

Title:

Address (if different from above):

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

Work Phone:

Cell:

Fax:

Email:

Primary Financial Contact

Name:*

Title:

Address (if different from above):

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

Work Phone:

Cell:

Fax:

Email:

Additional Contacts

Please list name title, address, phone/cell/fax, and email.

If needed, please provide notes below.

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).*

DEPOSIT PROCESS

What is your preferred deposit method?*

EMSMC deposits (on your behalf)
Alternative method: Lockbox (we will need access to this box)
Other: Client makes deposit

Is your bank local only?

Yes, it is only local
No, there are branches in Northwest North Carolina

If there are branches in Northwest North Carolina, you will need to provide EMS|MC with deposit slips. Please provide contact name and phone number.

Please select which type of fund.

EMS-only account
General fund

Name as it appears on bank account:

Name of Financial Institution:

Bank Address

Street Address Address Line 2 City State ZIP Code

PAYER INFORMATION

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

Is this Tax ID shared with another agency who would file healthcare claims? Example: Health Department*

Please provide your National Provider Identification (NPI) number:*

Please provide provider ID numbers and effective dates for the following: Medicare, Medicaid, Railroad Medicare, BlueCross BlueShield,, Tricare, Dept. of Labor, and UnitedHealthcare

What percentage of your payer mix is Medicare? Medicaid?*

Additional provider ID numbers and effective dates can be uploaded as a separate sheet.

Drop files here or

Do you regularly transport patients who reside in another state? If so, which states?*

Are you contracted (a participating provider) with any commercial insurance companies? If so, which ones?*

Yes
No

With which insurances are you contracted? Please list the effective dates for each.*

Please upload a copy of the contract(s).

Drop files here or

TEST

Select All
First Choice
Second Choice
Third Choice

Do you receive Electronic Fund Transfers (EFTs) from any of the following payers? Please select all that apply.

Hold down the Ctrl key to select multiple choices.

Please list the other payers from whom you receive EFTs.

Do you receive electronic remits from any of the following payers? Please select all that apply.

Hold down the Ctrl key to select multiple choices.

Please list the other payers from whom you receive electronic remits.

Do you have access to websites for remits from any of the following payers? Please select all that apply.

Hold down the Ctrl key to select multiple choices.

Please list the other payers that grant you access to websites for remits.

If needed, please provide notes below.

ePCR Information

Who is your current ePCR vendor?*

If a hospital data exchange (HDE) is included with your ePCR, please list details below.

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

What is the QA level/status that you will mark trips within your ePCR when they are ready to be billed?*

How often do you QA trips and who is responsible?*

Do you have any additional agencies (ordering facilities) that you need to report on separately?*

Yes
No

Please list them below exactly as the unit names appear in your ePCR (punctuation, spacing, and upper/lower case are important).

We need the Agency Name, Address, City, State, Zip Code, Contact Name, Contact Phone number and email.

CUSTOMER SERVICE POLICIES

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

Yes
No

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

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)

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

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

Yes
No

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

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.

To whom should we send patient disputes regarding the provider service at the time of transport/care? Please provide name and contact information.*

Do you charge a returned check fee?*

Yes
No

What is your returned check fee amount?

Please enter a number greater than or equal to 0.

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.*

What is your county's emergency services phone number?

LEGAL AND ESTATES

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

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

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

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

Please explain your Area Residence/In-County billing procedures, if applicable. Please provide the determining factors for area residence status (i.e. zip code), if area resident patients will be responsible for deductible, insurance payments made directly to the patient, and non-covered services. If none, write "none".*

Please explain your Membership/Subscription program, if applicable. Please provide information about the pricing, effective dates, enrollment period, etc. If none, write "none".*

Do you bill ALS-level of service for ALS Assessments or based on services rendered? Please define your dispatch protocols/EMD codes (Alpha, Bravo, Charlie, etc.), if applicable.*

Please attach a copy of your dispatch protocols, if available.