Billing Support Pre-Onboarding Qualification
New billing clients begin with a short intake form so we can review your practice structure, claim volume, and payer mix. Based on this information, we will recommend the appropriate billing service tier.
SECTION 1: PRACTICE INFORMATION
Business Legal Name
*
DBA (if applicable)
Provider Name
*
First Name
Last Name
NPI 1
*
NPI 2
*
Practice Type
*
Solo Private Practice
Part-Time Private Practice
Transitioning from Agency
Other
Are you currently accepting insurance?
*
Yes
No (In credentialing process)
Private Pay Only
Phone Number
*
-
Area Code
Phone Number
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SECTION 2: CLAIM VOLUME & PAYERS
On average, how many claims do you submit weekly?
*
Under 20
20-40
40-60
60 +
Approximate monthly claim volume (number)?
*
Insurance Panels Currently Active
Do you bill in multiple states?
*
Yes
No
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SECTION 3: CURRENT BILLING STRUCTURE
Who currently handles billing?
*
I do it myself
Previous biller
Virtual assistant
No one
What EHR system are you using?
*
Do you have clearinghouse access?
*
Yes
No
Not sure
Do you have payer portals?
*
Yes
No
Some but not all
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SECTION 4: A/R & DENIALS STATUS
Do you currently have unpaid claims over 30 days?
*
Yes
No
Not sure
Estimated amount in outstanding A/R (if known)
*
Are there claims older than 60-90 days?
*
Yes
No
Not sure
Have you experienced recurring denials?
*
Yes
No
What is your most common denial reason?
*
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SECTION 5: WORKFLOW & READINESS
Are clinical notes completed within 24-48 hours of sessions?
*
Yes
Sometimes
No
Are benefits verified before services are rendered?
*
Yes
Sometimes
No
Are copays collected at the time of service?
*
Yes
Sometimes
No
Are you prepared to provide EHR and portal access within 5 business days of onboarding?
*
Yes
No
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SECTION 6: SERVICE AGREEMENT
What are you primarily seeking support with?
*
Claim submission
A/R follow-up
Denial resolution
Revenue organization
Clean-up support
Other
What is your biggest billing frustration right now?
*
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Section 7: TIER CONFIRMATION
I understand this form is created to determine which tier best fits my practice.
*
I understand
I understand investment begins at $650/month and final pricing is confirmed after review
*
I understand
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SECTION 8: AUDIT DISCLOSURE
I understand that if significant billing clean-up is required, a Billing Health Audit ($495) may be required before monthly services begin
*
I understand
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SECTION 9: AGREEMENT
I certify the information provided is accurate to the best of my knowledge.
*
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