Massachusetts HME Providers Business Capabilities Survey

HME Providers Business Capabilities Survey
1. What is the name of your company?*
2. Please enter the address(es) of your company's retail locations and fill out all information below. Use the "+" button if there are multiple locations. *
3. Does your organization service for urgent orders past 5:00 PM on weekdays and/or weekend orders? If so, please input it below.
4. What is your company's Tax Identification Number (TIN)? *
5. What is your MA State License #?:*
6. What is your fax number?*
7a. Please provide the first and last name of the individual who will be the point of contact for the onboarding of your organization:*

First NameLast Name
7b. What is their email address?*
example@example.com

8. Please indicate your dispensing capabilities per product categories below. Check all that apply. Note: You can adjust these selections on the HCPCS level later.*

	Deliveries via Driver	Deliveries via shipping carrier	Urgent Deliveries (Same Day)	Pediatric Referrals	Adult Referrals
Walkers & Rollators
Ventilators
Transcutaneous Electrical Nerve Stimulators (TENS)
Tracheostomy Supplies
Therapeutic Shoes
Surgical Dressings
Standard Wheelchairs
Prosthetics
Pressure Reducing Support Surfaces
Power Mobility
Pneumatic Compression
Patient Lift
Oxygen Contents & Equipment
Ostomy Supplies
Orthopedic Braces
Nutrition
Negative Pressure Wound Therapy
Nebulizers
Incontinence Supplies
Hospital Beds
Diabetic Shoes
Diabetic Supplies
Custom Burn Garments
Cough Assist, Stimulators and Vest Therapy
Catheters
Canes, Crutches, Knee Scooters
CPAP
Breast Pumps
Blood Pressure Monitors
Biliblankets
BiPAP
Bathroom and Bedroom Aids

9. Please indicate your dispensing capabilities for the following item that are dispense under HCPC E1399 and A999.*

Non-slip bathmatsPill boxStep StoolHandheld shower headsSock aidLong handled spongeReusable Cold PacksBio FreezeOTC Pain PatchesOTC 4% Lidocaine Patches or CreamSombra Gel (warming or cooling)Cotton Tipped ApplicatorsOral Swab SticksBody Cleansers and Foaming CleansersSharps ContainerWe do not dispense items under E1399 and A999Other
10. Please confirm your dispensing capabilities for the nutrition brands below.

BoostEnsureCarnation DrinksGerberNutramigenPedialyteGlucernaThick it- nutrition thickenerPeptamen JrJevityOsmoliteElecareKate FarmsCompleatNutrenIsosource
10a. Please upload a list of any other nutrition brands that you service below

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11. Tomorrow Health orders will be sent through our web-based platform. Please provide the names and email addresses of the individuals handling your organization's order intake. They'll receive an email from support@tomorrowhealth.com to set up their account on the platform. We suggest having at least 2-5 users. (Use the + button for multiple users)*
12. Are you currently in-network with Commonwealth Care Alliance (CCA)?*

YesNo
13. Please select all other insurances you are in-network with below. If selecting "Other", please use a semi-colon to list multiple health plans, or upload a list of insurances below.*

AetnaBCBS of MassachusettsBlue Benefit Administartors of MassachusettsCignaCommonwealth Care Alliance (CCA)ConnectiCare, Inc.Fallon HealthHarvard PilgrimHealth New EnglandHumanaMass General Brigham Health PlanMassHealthTufts Health PlansUnited HealthcareUnited Healthcare Community Plan MAWellSense Health PlanOther
Please upload a list of any other insurances you are in-network with below

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14. Please select all counties in Massachusetts that you service:*

Barnstable CountyBerkshire CountyBristol CountyDukes CountyEssex CountyFranklin CountyHampden CountyHampshire CountyMiddlesex CountyNantucket CountyNorfolk CountyPlymouth CountySuffolk CountyWorcester County
15. Please select all counties in Massachusetts that you service URGENTLY:*

Barnstable CountyBerkshire CountyBristol CountyDukes CountyEssex CountyFranklin CountyHampden CountyHampshire CountyMiddlesex CountyNantucket CountyNorfolk CountyPlymouth CountySuffolk CountyWorcester County
16. What Order Management System (OMS) solution do you use today?*

BrightreeNiko HealthBonafideTIMSDMEWorks!Custom / home-grown systemWe do not use a system, we manually track referralsOther
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