In order for us to provide a more accurate quote, please print and  fax this form to:  609-259-0982

or 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                                                                                               

       Emdeon clearinghouse registration and major carrier notification

       Lytec 2008, practice database set up

       Network evaluation

       Customized superbill set up with code and fee analysis

       Front desk workstation set up

       Start Up Practice

·  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

   Lytec Scheduler (included with System Hosting clients)

   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-9 or CPT coding assistance

 In office staff training (number of staff members___)

 Other, please specify_________________________