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Vendor/Billing Service/Clearinghouse Survey

Company Name:

Software Product Name:
Company Type (required) (check all boxes that apply):
   Vendor     Billing Service  Clearinghouse
Vendor/Submitter # (required):

Address:

Street:
City: State: Zip:

Contact Information to be used by Empire Medicare Services:
Contact Name (required):

 

Title (required):
Telephone (required):
E-Mail Address (required):
Note: Empire Medicare Services maintains a ListServ to notify EDI Software Vendors, Billing Services and Clearinghouses of important information. You must provide at least one email address.
Contact Information to be published on our Web site:
Company Name:

 
Software Product Name:
Software Version:
Contact Name:

 
Web site Address for Publication:
Address:

Street:
City: State: Zip:

Telephone:
E-Mail Address:
Post to our Web? (required):   Yes     No
Please review all questions below. 
Medicare reserves the right to verify your qualifications, which may result in exclusion from the list. All questions below must be answered. 

Do you offer:

·        ANSI ASCX12N 837 4010A1 electronic claim submission?
Yes     No

·        Direct transmission of claims to Empire and report retrieval via AT&T Net Client Network (IVANS) and e-Link?
Yes     No

·        Claim Transmission via a clearinghouse?
Yes     No

·        ANSI ASCX12N 997 Functional Acknowledgement?
Yes     No

·        ANSI ASCX12N 997 Functional Acknowledgement programmed in a readable format?
Yes     No

·        Submission Summary Report?
Yes     No

·        Electronic Funds Transfer (EFT)?
Yes     No

·        ANSI ASCX12N835 Electronic Remittance Advice (ERA)?
Yes     No
(including product promotion and customer education regarding ERA availability, retrieval, usage and ramifications).

·        Do you provide and support automatic posting of the Medicare B remittance? 
Yes     No

·        Do you support the claim status inquiry transaction (276-277)?
Yes     No

·        Software and Hardware Support?
Yes     No

·        High quality customer service standards, including:

    • Educate clients on the availability, time frame, and retrieval process of EDI reports, as well as providing instructions for reading and interpreting these reports?
      Yes     No
    • Maintain an Internet e-mail address for communication with customers and with EDI Services?
      Yes     No

·        Provide onsite training? 
Yes     No

·        Advise your clients to download the remittance advice and use ‘MEDICARE REMIT EASY PRINT (MREP) ’ software to view and print remittance information?
Yes     No

·        Do you provide and support automatic posting of the Medicare Part B Remittance
Yes     No

·        If as a Billing Service or Clearinghouse, do you parse the data contained in the MCS Edit Report and send directly to providers who billed the services?
Yes     No

·        If as a Billing Service or Clearinghouse, do you parse the data contained in the Medicare ERA and send directly to providers who billed the services?
Yes     No

·        Hard code variable data in your system that affects the processing and adjudication of Medicare claims?
Yes     No

·        Persuade customers to obtain access to the Internet for conducting Medicare research and reading provider education publications?
Yes     No

·        Persuade customers to Subscribe to the Empire Medicare Service “ELECTRONIC MAILING LIST’ to receive notifications via e-mail?
Yes     No
Only those companies who complete and return the 2006 survey by the deadline (even if you completed a survey in the past) will be posted to our Web site.  Surveys received after the deadline are not guaranteed for inclusion in the list.

Page Last Modified: 09/26/2006

 
   
 
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