MittenPoint Health Partners — Free Revenue Cycle Review: Report Totals
Copy the totals from your billing reports into the boxes below. We only need summary numbers. Do NOT enter patient names, birth dates, member IDs, account numbers, or any other patient information anywhere on this form. Leave a box blank if you don't have that number.
About your practice
Practice name
*
Your name
*
Your role
*
Please Select
Owner
Office/Practice Manager
Biller
Other
Email
*
example@example.com
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
A/R aging report
From your A/R aging report, aged from date of service, balances net of credits.
A/R report as-of date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Total A/R ($)
*
A/R 0-30 days ($)
*
A/R 31-60 days ($)
*
A/R 61-90 days ($)
*
A/R 91-120 days ($)
*
A/R over 120 days ($)
*
Charges for the 3 months before your A/R date
Period start date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Period end date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Total charges in this period ($)
*
Last 12 months
From your charges / payments / adjustments summary.
Total charges, 12 months ($)
*
Total payments received, 12 months ($)
*
Insurance plus patient payments. Do not include incentive or bonus payments.
Refunds, 12 months ($)
Contractual adjustments, 12 months ($)
Bad-debt write-offs, 12 months ($)
Claims
Use the same 3 to 6 month period for every box. Count first submissions only.
Claims period start date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Claims period end date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Claims submitted
*
Claims rejected by the clearinghouse before reaching the payer
*
Claims denied on the first payer response
*
Dollar total of claims submitted
Dollar total of claims initially denied
Charge entry (optional)
Average days from visit to charge entry
Charge lines entered in the period
Late charge lines entered after your posting cutoff
Attestations
I confirm this form contains only summary totals and no patient information.
*
I confirm
Where did these numbers come from?
*
Copied from our billing reports
Estimates / from memory
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