In order for us to provide a more accurate quote, please print and  fax this form to:  1-877-263-3245

Comprehensive Forms: Print and fax:   Practice Information Forms--word

Comprehensive Forms: Print and fax:  FORMS--pdf

Brief Form: FORM- word

or mail to: NMBS LLC, 7 Nolan Rd, Allentown, NJ 08501 

To complete a proposal ONLINE, go to: registration,  and send inquiry electronically.

Comprehensive forms; details:

NetProphets Medical Billing - Practice information Forms Please complete this introductory survey, and fax to our office so we may provide you with a competitive quote.                                 Date: ___________________________

Name of Provider: ___________________________________________

Specialty: _________________________________________________

Name of Practice: ____________________________________________

Address: ___________________________________________________

__________________________________________________________

Phone: _____________________________________________________

Fax Number: _________________________________________________

E-mail address: _______________________________________________
Website: ____________________________________________________

How long has the provider been in practice at this location? ________________

Are there other providers working for this practice?
No_____ Yes ______   If yes,
Name/Specialty _______________________________________    
Name/Specialty _______________________________________     Name/Specialty _______________________________________     Office Manager: ________________________________________
Office Hours: __________________________________________
Taking New Patients? Yes_______   No_______
Average number of patients per week: _______________
Current Dollar Amount on the Practice Accounts Receivables? _________________________AND/ OR:  Average collected Receipts monthly? ____________________________________
Average claims per month? __________ Average price per claim? ____________Approximate number of active accounts? _______________________________What is your insurance rejection rate?  0-10%___ 10-20%___ 20-30%_______How many Patient Statements do you send (or plan to send) each month? ______ Approximate Breakdown of Patient Types per week:

Self Pay:____________________________________
Workers' Comp:_______________________________
Auto:_______________________________________
Government:_________________________________
Medicare:___________________________________
Medicaid:___________________________________
Commercial Par:_______________________________
Commercial Non-Par:___________________________
HMO Par:____________________________________
HMO Non-Par:_________________________________
Blue Cross/Blue Shield:__________________________


Does provider collect copays at time of service?__________
Does provider collect deductibles at time of service:_______
Number of office staff: ______________
Does Staff work accounts receivables? _______________
Does Staff submit claims? _________________________
If no, who does: _________________________________
Does Provider bill self pay patients? __________________
If not, who does? ________________________________
How do self pay patients pay? _________________________________________________
Approximate number of mail returns per week? ___________
Does provider bill secondary insurance carriers? ___________

Does provider use a collection agency for delinquent accounts? ___________
If Yes, Name of Agency: _______________________________
Percentage Amount Collection Agency Invoices: _________
How old is the account when sent to the collection agency? ___________________

Does Provider Have Contracts any HMO? Yes___ No___
If Yes, which?
________________________________________________________________________________________________________________________________________________

Contracts with Non-HMO Carriers?
Yes: ______ No: _______ If Yes, which ones?
________________________________________________________________________________________________________________________________________________
Is provider Capitated with any Carriers? Yes___ No___
If yes, which ones? ________________________________________________________________________

Does Provider have contracts that have timely filing limits of 120 days or less?Yes ____ No_____
_______________________________________________________________________

Does Provider use Lockbox? Yes____ No____
If Yes, Name of Bank: _______________________________________________________________________

Does Provider have financial Plan: Yes____ No_____

Does provider have “Assignment of Benefits” form? Yes____ No____
If Yes, is form signed by patient/guardian at time of service? _____________

Does provider have Time Payment Plans? Yes____ No____
Does Provider have compliance plan? Yes____ No_____
When was fee schedule last updated? ______________
When was Superbill Updated? ____________________Does the provider send claims electronically? __________
Which clearinghouse is currently being used: ___________

Is provider affiliated with a hospital(s)? Yes____ No____
If yes, Name(s) of Hospital: ________________________________________________________________________

 


How many computers are being used in the practice? ____

Are the computers networked?    Yes_____No_________Do your computers have internet access? Yes____No____

What Internet method are you currently using?  Dial up ____     DSL____    Cable____What is the highest broadband speed available?  DSL_____     Cable_____
Are the computers:  Owned_____    Leased______  ?
What type of computers are they? ________________________________________________________________________
________________________________________________________________________

Does the provider have a scanner? Yes____ No____

please check off the services below which you anticipate needing:

·        Office set up                                                                                          

  

     

       Network evaluation

       Customized superbill set up with code and fee analysis

       Front desk workstation set up

       Start Up Practice/ Credentialling

·  Core Service

       Patient Information data entry

       Charge Entry

       Claim Editing & Electronic submission

       Payment Posting

       ERA/EFT

       Secondary Paper claims

       Denial follow up; appeals; calls

       Accounts receivable review

       Weekly, monthly, customized reports

       Weekly Mailer for superbills/encounters

       Unlimited Fax of superbills/encounters

       Email addresses for staff

       Online support & training

·  Additional Services

  

   Patient Statement Billing(three cycle)

   Past Due/Delinquest Collection

   Data Migration from Lytec program

 Data Migration from non Lytec program

 Provider Enrollment

 Provider credentialing

 ICD-10 or CPT coding assistance

 In office staff training (number of staff members___)

 Other, please specify_________________________