1. Please provide an email address for verification purposes. Responses that do not include a valid email address will not be counted. We will not use your address for any other purpose, nor will we pass it along to any third party.
 Total Respondents  
0
(skipped this question)  0
2. The care setting I work in can best be described as:
 Response PercentResponse Total
  Individual or Group of Physicians (MD, DO, DDS, DMD)
0%0
  Hospital, Nursing Facility, Health System or other Institutional Setting
0%0
  Other (includes Ambulance, Lab, Pharmacy, DME and all other clinics and practitioners)
0%0
Total Respondents  0
(skipped this question)  0
3. The institution I work in can best be described as
 Response PercentResponse Total
  Multi-Hospital Health System
0%0
  Acute Care Hospital
0%0
  Critical Access Hospital
0%0
  Specialty (i.e. Cardiac, Psychiatric, Substance Abuse, or Rehab Hospital or Facility)
0%0
  Outpatient Facility (Surgical center, Rehab Facility, Urgent Care, etc.)
0%0
  Hospice
0%0
  Dialysis/ESRD
0%0
  Intermediate Care Nursing
0%0
  Skilled Nursing Facility
0%0
  Other nursing facility
0%0
  Other (please specify)
0%0
Total Respondents  0
(skipped this question)  0
4. For this type of facility, I would describe our institution as
 Response PercentResponse Total
  Large
0%0
  Medium
0%0
  Small
0%0
  Not sure
0%0
Total Respondents  0
(skipped this question)  0
5. The number of physicians/practitioners in this practice is:
 Response PercentResponse Total
  1
0%0
  2 - 9
0%0
  10-25
0%0
  26-50
0%0
  Over 50
0%0
Total Respondents  0
(skipped this question)  0
6. The practitioner(s) in this facility can be categorized as follows (check all that apply).
 Response PercentResponse Total
 Addiction Medicine
 0%0
 Allergy Immunology
 0%0
 Anesthesiology
 0%0
 Cardiac Surgery
 0%0
 Cardiology
 0%0
 Colorectal Surgery
 0%0
 Critical Care (Intensivists)
 0%0
 Dentistry (i.e. DDS or DMD)
 0%0
 Dermatology
 0%0
 Diagnostic Radiology
 0%0
 Emergency Medicine
 0%0
 Endocrinology
 0%0
 Family Practice
 0%0
 Gastroenterology
 0%0
 General Practice
 0%0
 General Surgery
 0%0
 Geriatric Medicine
 0%0
 Gynecological/Oncology
 0%0
 Hand Surgery
 0%0
 Hematology
 0%0
 Hematology/Oncology
 0%0
 Infectious Disease
 0%0
 Internal Medicine
 0%0
 Interventional Radiology
 0%0
 Maxillofacial Surgery
 0%0
 Medical Oncology
 0%0
 Nephrology
 0%0
 Neurology
 0%0
 Neuropsychiatry
 0%0
 Neurosurgery
 0%0
 Nuclear Medicine
 0%0
 Obstetrics Gynecology
 0%0
 Ophthalmology
 0%0
 Oral Surgery
 0%0
 Orthopedic Surgery
 0%0
 Osteopathic Manipulative
 0%0
 Otolaryngology/Otorhinolaryngology
 0%0
 Pain Management
 0%0
 Pathology
 0%0
 Pediatric Medicine
 0%0
 Peripheral Vascular Disease
 0%0
 Physical Medicine and
 0%0
 Plastic and Reconstructive
 0%0
 Preventive Medicine
 0%0
 Psychiatry
 0%0
 Pulmonary Disease
 0%0
 Radiation Oncology
 0%0
 Rheumatology
 0%0
 Surgical Oncology
 0%0
 Thoracic Surgery
 0%0
 Urology
 0%0
 Vascular Surgery
 0%0
 Other (please specify)
 0%0
Total Respondents  0
(skipped this question)  0
7. Please indicate the approximate number of employees (Full Time Equivalent) in the organization you represent
 Response PercentResponse Total
  1-5
0%0
  6-25
0%0
  26-100
0%0
  101-500
0%0
  Over 500
0%0
Total Respondents  0
(skipped this question)  0
8. Please indicate the type of health care provider you represent (click as many as apply).
 Response PercentResponse Total
 Ambulance Service Provider
 0%0
 Ambulatory Surgical
 0%0
 Audiologist
 0%0
 Certified Clinical Nurse
 0%0
 Certified Nurse Midwife
 0%0
 Chiropractic
 0%0
 Clinical Laboratory
 0%0
 Clinical Psychologist
 0%0
 CRNA, Anesthesia Assistant
 0%0
 DME
 0%0
 Home Health Agency
 0%0
 Independent Diagnostic
 0%0
 Independent Physiological
 0%0
 Individual Certified Orthotist
 0%0
 Individual Prosthetist
 0%0
 Licensed Clinical Social Worker
 0%0
 Mammography Screening
 0%0
 Medical Supply - DME
 0%0
 Medical Supply - Prosthetic/Orthotic
 0%0
 Nurse Practitioner
 0%0
 Occupational Therapist
 0%0
 Optician
 0%0
 Optometry
 0%0
 Pharmacy
 0%0
 Physical Therapist
 0%0
 Physician Assistant
 0%0
 Podiatry
 0%0
 Portable X-Ray Supplier
 0%0
 Psychologist
 0%0
 Public Health or Welfare
 0%0
 Registered dietician
 0%0
 Other (please specify)
 0%0
Total Respondents  0
(skipped this question)  0
9. For each claim/attachment type listed below, rate the frequency you must submit them to collect payment on a claim. If at attachment type does not apply to your line of business, check N/A.
Almost AlwaysFrequentlySometimesRarelyNeverN/AResponse Average
Laboratory Results
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Medications (not prescriptions)
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Clinical Reports (examples include: anesthesia, arthroscopy, cardiac catheterization, colonoscopy, consultation note, cytology report, discharge note, echo heart, EEG brain, endoscopy, flexible sigmoidoscopy, initial assessment, nursing, OB, procedure note, radiology, surgical pathology, visit note)
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Alcohol-Substance Abuse Rehabilitation
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Cardiac Rehabilitation
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Medical Social Services Rehabilitation
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Occupational Therapy Rehabilitation
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Physical Therapy Rehabilitation
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Speech Therapy Rehabilitation
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Respiratory Therapy Rehabilitation
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Psychiatric Rehabilitation
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Skilled Nursing Rehabilitation
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Emergency Department
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Ambulance Service
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Durable Medical Equipment (DME)
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Home Health Services (skilled nursing in the home)
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Periodontal Services
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Children's Preventive Health Services
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Consent (for sterilization/hysterectomy)
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Administrative/non clinical information
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Total Respondents  0
(skipped this question)  0
10. List any other types of additional information that are frequently required or requested for adjudication of your claims.
 Response PercentResponse Total
  1)
0%0
  2)
0%0
  3)
0%0
Total Respondents  0
(skipped this question)  0
11. When we send attachments, we generally
Almost AlwaysFrequentlySometimesRarelyNeverN/AResponse Average
Include the attachment with the original claim
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Wait for the payer to request the attachment
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Total Respondents  0
(skipped this question)  0
12. Within our own organization, this attachment information is available as
Almost AlwaysFrequentlySometimesRarelyNeverN/AResponse Average
A scanned image
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
A computer document (i.e. MS Word)
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
A report printed by an application
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
A paper form
0% (0)0% (0)0% (0)0% (0)0% (0)0% (0)0.00
Total Respondents  0
(skipped this question)  0