HME Providers Business Capabilities Survey
1a. What is the name of your company?
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1b. Please list any additional company names or DBAs that your company may bill as or be known as:
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.
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3. Does your organization service for urgent orders past 5:00 PM on weekdays and/or weekend orders? If so, please input it below.
4a. Please list all Taxpayer Identification Numbers (TIN) that your company many use for billing. Separate by comma.
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4b. Please list all National Provider Identifier (NPI) that your company many use for billing. Separate by comma.
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4b. Please list any additional TINs that your company many use for billing.
4c. Does your business qualify under any of the below Diversity Equity and Inclusion (DEI) designations? Please select all that apply.
Minority Business Enterprise (MBE)
Women Business Enterprise (WBE)
Veteran-Owned Small Business (VBE)
Service-disabled Veteran Owned (SDVBE)
LGBT Business Enterprise (LGBTE)
Disabled Owned Business Enterprise (DOBE)
Disadvantaged Business Enterprise (DBE)
Small Business Enterprise (SBE)
Small Diverse Business Enterprise (SDB)
Small Business (SB)
Women-Owned Small Business
HUBZone – SBA
5. What is your MA State License #?:
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5a. Which bodies is your company are accredited with?
Accreditation Commission for Health Care (ACHC)
Board of Certification/Accreditation (BOC)
Community Health Accreditation Partner (CHAP)
We are not accredited
Other
5b. Please upload proof of accreditation
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6. What is your fax number?
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7a. Please provide the first and last name of the individual who will be the point of contact for the onboarding of your organization:
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First Name
Last Name
7b. What is their email address?
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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.
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Rows
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.
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Non-slip bathmats
Pill box
Step Stool
Handheld shower heads
Sock aid
Long handled sponge
Reusable Cold Packs
Bio Freeze
OTC Pain Patches
OTC 4% Lidocaine Patches or Cream
Sombra Gel (warming or cooling)
Cotton Tipped Applicators
Oral Swab Sticks
Body Cleansers and Foaming Cleansers
Sharps Container
We do not dispense items under E1399 and A999
Other
10. Please confirm your dispensing capabilities for the nutrition brands below.
Boost
Ensure
Carnation Drinks
Gerber
Nutramigen
Pedialyte
Glucerna
Thick it- nutrition thickener
Peptamen Jr
Jevity
Osmolite
Elecare
Kate Farms
Compleat
Nutren
Isosource
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)
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12. Are you currently in-network with Commonwealth Care Alliance (CCA)?
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Yes
No
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.
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Aetna
BCBS of Massachusetts
Blue Benefit Administartors of Massachusetts
Cigna
Commonwealth Care Alliance (CCA)
ConnectiCare, Inc.
Fallon Health
Harvard Pilgrim
Health New England
Humana
Mass General Brigham Health Plan
MassHealth
MassHealth Primary Care Clinician (PCC)
Molina Healthcare of Massachusetts
Tufts Health Plans
United Healthcare
United Healthcare Community Plan MA
WellSense Health Plan
Other
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:
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Barnstable County
Berkshire County
Bristol County
Dukes County
Essex County
Franklin County
Hampden County
Hampshire County
Middlesex County
Nantucket County
Norfolk County
Plymouth County
Suffolk County
Worcester County
15. Please select all counties in Massachusetts that you service URGENTLY:
Barnstable County
Berkshire County
Bristol County
Dukes County
Essex County
Franklin County
Hampden County
Hampshire County
Middlesex County
Nantucket County
Norfolk County
Plymouth County
Suffolk County
Worcester County
16. What Order Management System (OMS) solution do you use today?
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Brightree
Niko Health
Bonafide
TIMS
DMEWorks!
Custom / home-grown system
We do not use a system, we manually track referrals
Other
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