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.

Drop files here or

Do you have contracts with any facilities? (i.e. Prison, County/City Jail, Hospice, Nursing Facility, Hospital, etc.)*

Yes
No

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

Drop files here or

Do facility contracts include language for PCS/medical necessity form requirements?*

Yes
No

Please provide instructions for special invoicing and balance billing patients from these facilities (i.e. Prison, County/City Jail, Hospice, Nursing Facility, Hospital, etc.)*

Please explain your policy for billing hospice patients if the hospice facility denies and the patient does not have insurance. Do you want EMS|MC to balance bill the patient or write off the remaining balance?*

Please list hospice facilities below. Please include name, address, and contracted rate. If none, list "None."*

Please explain your policy for billing indigent/homeless patients. If you use collections, do you wish to send these patients to collections? Additionally, please list any known homeless facilities/addresses in the area.*

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.

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

Yes
No

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

If available, please attach copy of agreement(s).

Drop files here or

Do you have a special policy for billing employees and other public safety personnel? If so, does this policy extend to on and off duty personnel? Does it extend to just medics, or any member of public safety and/or city/county employee? Where will you notate this information on the PCR?*

How do you collect Patient Signature Authorizations?*

Attachment
Electronic Capture

How do you collect the Medical Record Author's signature?*

Attachment
Electronic Capture

Please explain your policy for billing non-emergency transports, including prior authorization documentation. EMS|MC requires medical necessity forms such as a Physician Certification Statement (PCS) or EMTALA form to bill scheduled transports.

Please state your billing policy for the following Deceased On Arrival (DOA) scenarios: Patient deceased prior to dispatch, patient pronounced dead at scene, and patient pronounced enroute or upon arrival at hospital

Please explain your Treatment No Transport (TNT) billing policy (be specific i.e. Bill as BLS-E? Cancel? Charge different rate based on services rendered, i.e. whether it is only a lift assist response, MVA response, or certain supplies are used).

COLLECTION PROCESS CONTINUED

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:

Do you itemize for supplies, oxygen, etc?

Yes
No

Please upload a detailed list via separate sheet.

Do you provide air medical services?*

Yes
No

Please provide a copy of your 135 license certification.

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

Please provide a list of frequently used landing zones.

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

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

Please provide air protocols below.

Alternatively, please attach copies of your air protocols.

Please provide your air rates below.

Alternatively, please attach a list of your air rates.

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

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

COLLECTION PROCESS CONTINUED

Is your county mandated to provide ALS services?

Yes
No

Are all ambulances staffed at the paramedic level?

Yes
No

Do you have any paramedics with critical care credentialing?

Yes
No

Please provide EMS|MC with a list of their names:

Please attach an Excel spreadsheet with the names, credentials and email addresses of all staff members.

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

Yes
No

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

Yes
No

Please explain the narrative preference.

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

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

Yes
No

Insurance information?

Yes
No

Social Security Number?

Yes
No

Area Residence status (if applicable)?

Yes
No

Annual Membership/Subscription status (if applicable)?

Yes
No

OPUS # (North Carolina Correctional Facility Inmate Number) ?

Yes
No

Medical Record Documentation/Number?

Yes
No

Out-of-county mileage?

Yes
No

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

FACILITY AND HOSPITAL INFORMATION

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

Hospitals you Transport to:

Please list the Hospital Name, Estimated Annual Volume Number, Estimated Annual Volume Percentage, Address, and a point of contact for us (name, number, email).

Nursing Facilities you Transport to:

Please provide the Name and Address as well as a point of contact for each facility (name, number, email).

Do you provide emergency medical services in North Carolina?

Yes
No

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

If needed, please provide notes below.

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

Do you use collections?*

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

To whom should we send the collections file?

Phone number:

Email address:

Which agency will you be using?

Contact person at Collection Agency:

Phone number:

Email address:

Address:

Street Address Address Line 2 City State ZIP Code

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

Provide to us
Provide to collection agency

If provided to the collection agency, do you require time to review beforehand?

Yes
No

Who will be our contact for the collections report?

What is the minimum amount to be written off and not sent to collections?

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

Yes
No

Will EMS|MC be preparing your tax garnishment/debt set off file?

Yes
No

Who will be our contact for the tax garnishment/debt set off report?

Phone number:

Email address:

How often do you submit your file to the state?

Annually
Quarterly

Do you currently participate in a wage garnishment program?

Yes
No

Who will be our contact for the wage garnishment report?

Phone number:

Email address:

If no to any of the above, would you like information on any of these programs?

Hold down the Ctrl key to select multiple choices.

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

Who should receive these requests?

Will you accept monthly payments?

Yes
No

What is the minimum payment amount you will accept?

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

Yes
No

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.

If needed, please provide notes below.

EMS|MC REPORTING INFORMATION

Please list the name and email of the person to receive each report below:*

ACR Return to Provider Report (PCR documentation clarification report available 24/7 via EMSight Client Portal Website)	ACR Return to Provider Report (Daily (or as completed) notification of trips placed on report via email)	Constant Contact Email (Global alerts and notifications from EMS\|MC via email)	EMS\|MC Invoice (Monthly via email)	Import Confirmation (Trip import report sent as completed via FTP)	Missing Signatures (Signature documentation feedback sent weekly via FTP)	Month-End Report (Financial reports sent monthly via FTP)	Payment Summary (Deposit workbook and payment information available 24/7 via EMSight Client Portal Website)	Refunds (Refund information sent weekly or as completed via FTP)

If needed, please provide notes below.

FORM SUBMISSION

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

Please list only one email address.

EMS AGENCY DATA

EMS AGENCY CONTACTS

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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