HONEY BEE BEHAVIORAL BILLING
CLIENT ONBOARDING QUESTIONNAIRE & IMPLEMENTATION FORM
Thank you for choosing Honey Bee Behavioral Billing. Please complete the following information to assist with implementation, billing setup, credentialing, and account management.
PRACTICE INFORMATION
Practice Name:
DBA (If Applicable):
Primary Contact Name:
Title:
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Practice Address:
Website:
Tax ID (TIN):
Group NPI:
Practice Management System/EHR:
Clearinghouse:
BILLING PREFERENCES
How frequently would you like claims generated and submitted?
Daily
Preferred Time of Day:
Weekly
Preferred Day of Week:
Other
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How frequently would you like patient statements generated?
Our standard process is once monthly.
How frequently would you like patient statements generated?
Monthly (Recommended)
Bi-Weekly
Weekly
Other
Please Explain:
PATIENT PAYMENT PROCESSING
How do you currently process patient payments?
How do you currently process patient payments?
Integrated within Practice Management System
Merchant Account
Stripe
Square
Authorize.net
Other
Please Specify:
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PATIENT FINANCIAL POLICIES
Payment Plans
Do you offer payment plans?
Yes
No
Minimum Monthly Payment:
Maximum Payment Plan Length:
Additional Terms:
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PATIENT COLLECTIONS PREFERENCES
Number of patient statements to send before collections:
Number of patient statements to send before collections:
3 Statements
4 Statements
Other
Collections Agency
Do you currently utilize a collections agency?
Do you currently utilize a collections agency?
Yes
No
If Yes: Agency Name:
Would you like to utilize Honey Bee Behavioral Billing's collections partner?
Yes
No
When should delinquent balances be eligible for collections?
90 Days
120 Days
180 Days
Please Specify:
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IMPLEMENTATION PRIORITIES & CURRENT CHALLENGES
Please check all current challenges that apply:
Current Challenges
Outstanding Accounts Receivable (A/R)
Aging Claims Over 90 Days
Credentialing Delays
Contracting Needs
Prior Authorization Issues
High Denial Rate
Payment Posting Backlog
Unworked Insurance Follow-Up
Secondary/Tertiary Claims Issues
Patient Collections
Patient Statement Concerns
Missing ERA/EFT Enrollments
Clearinghouse Rejections
Practice Management System Setup
Provider Enrollment Updates
Other
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What are your top three priorities for Honey Bee Behavioral Billing during the first 90 days?
2.
3.
Is there a specific implementation deadline or go-live date?
No
Yes
Target Date:
-
Month
-
Day
Year
Date
ADDITIONAL NOTES
AUTHORIZED REPRESENTATIVE
Name:
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Should be Empty: