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Registering for Chili Medical Billing Services

All new clients must start with a "clean" starting date (one that falls between the last 60 days and any reasonable date in the near future). (Older start dates are considered to be a part of our A/R Recovery services).

The date you choose will be the first day we start implementing our services. This date will also serve as the first date of service to be accepted (as reported on your superbills/treatment forms) for processing by our office!

After printing a blank copy of this Registration Form...please complete it in its entirety and include any additional information we have requested. Be sure to enclose your registration fee (if applicable), and send to:

Chili Medical Billing Services

3469 Chili Avenue

Rochester, NY 14624

Please indicate below, on what day you would like for us to begin our services? (This date can be within the previous 60 days, or any future date to come):

_____________________, ______ 2006

**You will be notified in advance if the start date indicated above is unavailable. If it is, your alternate starting date will be used instead (listed below).

Please indicate your alternate starting date below:

ALTERNATE START DATE:_________________, ______ 2006

(or circle one option below)

ASAP FOLLOWING DAY FOLLOWING WEEK FOLLOWING MONTH

Practice Name:____________________________________________________________

Address:_________________________________________________________________

City:________________________________State:______________Zip:_______________

Phone# ___________________________ Alternate Phone#______________________

Fax#______________________________

Email Address: ______________________________________

Tax I.D. #: __________________________________________

Are you a member of either of these organizations?: CDC BBB MCMS

Services & Products Desired- please indicate your choice(s) below:

Claims Filing Only

Full Billing Services

AR Recovery **Please complete our Free Consultation Form first! We will contact you afterwards.

Consulting

Practice (Group) ID Numbers: (all carrier payments will be to the Group, as specified below, otherwise the carriers will issue all payments to each individual provider)

Medicaid________________________________________

Medicare________________________________________

Other (Please Specify)_____________________________

Physician 1: For additional physicians and/or ID #'s, please copy this sheet or add information on an additional sheet of paper.

Specialty:___________________________________

( ) Group ( ) Fee For Service

Full Name:______________________________ License #:______________

Individual Medicaid Provider #:_____________________________________

Individual BCBS Provider #:________________________________________

Individual Medicare Provider #:_____________________________________

Medicare UPIN #:_____________________________________

( ) PAR ( ) NON PAR

Individual Other #:_______________________________________________

PLEASE SEE Service Checklist & Instructions!

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Revised: November 02, 2006

Sending Us Your Billing Information

You may begin sending us your billing/patient information as soon as we receive your check for registration, and a signed contract on file. Listed below are the guidelines to use when sending us your information:

With each new patient:

Patient Information Sheet: This form includes your patient demographic information. The form that is filled out in your office by your patient will suffice, should it lack in necessary information which is required to file your claims we will notify you.

Superbill/Treatment Form: This must include ICD-9 and CPT codes, dates of service, your signature, etc.

Copy of Insurance Card: Front and Back

Verification of Patient's Benefits

Insurance Authorizations/Referrals- must include Referring Physician name, address, phone, and license #.

Routinely:

Patient Payment (Log Sheet) – cash, credit card, check receipts

Copies of all Insurance Carrier Remittances/Payments (EOB’s, EOMB’s)

Any other documents that relate to claims, patients, or patient accounts, and insurance carriers.

Superbills/Treatment Forms

Updated Authorizations/Referrals

Important: Please do not send us a portion of the 4 pieces of information required for new patients. If you are waiting on something to complete these 4 pieces of information, hold the information in your office until you have everything and it has been stapled together. You may still send us your Encounter Slip for billing, provided that we have a New Patient Information Sheet on file. The charges will be logged into the computer and the patient will be placed on our "Incomplete Claims" Report. Once the additional required information has been received the claim(s) will be submitted.

Remember: If we receive information that is not readable or incomplete, it will either be sent back to your office or placed on hold, thus delaying submission of your claims. Please check the information before sending it to us.

We can only be as strong as the link between the practice and billing center. We are dedicated to providing you with excellent service, but can only do this if the information we receive allows us to.

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Revised: November 02, 2006

When and How To Submit Information

You will be sending us your information weekly in a Weekly Submittal Envelope unless alternative arrangements for pick up have been agreed upon (daily faxes, etc). Listed below are the guidelines for your Weekly Submittal Envelope::

New Patient Information (4 pieces stapled together)

Changes of Information (Patient, Diagnosis, or Insurance, etc.)

Copies of your Encounter Slips/Superbills/Treatment Forms

Copies of the EOB's & Patient Payments Received During The Week.

Miscellaneous Items (Status Requests, Questions, Insurance Updates, etc.)

Tips:

Include your patient’s file number on their patient information form as well as on the Encounter Slip.

Mail your submittal envelope consistently on the same day of each week (unless alternative arrangements are made). Friday's are usually a good day to submit your envelope for the entire week’s services. Claims are submitted from our office on a daily or as needed basis, which ever is applicable.

We will provide you with a sheet of mailing labels for your Submittal Envelopes (as needed). If you begin to run low please let us know and we will send you more.

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Revised: November 02, 2006

Posting Payments & Tracking Services

Once you begin receiving your EOB's from the insurance’s that we have filed for you, it is necessary for you to copy these EOB's each day when they arrive. Designate a stack tray or an area for Chili Medical Billing Services information. Please copy anything and everything that you receive from an insurance company that we are handling. This will allow us to keep your patient’s ledgers up to date as well as track your claims for complete collection. Your EOB's should be sent to us weekly with your Billing Information unless other arrangements are made and agreed upon.

Once we have filed a claim and have given a sufficient amount of time for your claim to reach the insurance company, we will call the insurance to check the status of your claim.
If we receive an EOB denying certain procedure’s, after making sure that your diagnosis and procedure format is correct, we will then submit a Letter of Medical Necessity for the procedure(s) that have been denied. You will receive a copy of this letter attached to a copy of the unfavorable EOB. We will then follow up for payment.
If you receive an EOB requesting a narrative report, office notes, etc…please forward a copy of this EOB to us with an authorized signature on the EOB showing that you are aware of the request. Once the report has been mailed to the insurance (please always include a copy of their EOB with your report) send us another copy of the EOB showing the date that the report was mailed to the insurance. We will then pursue for payment.
In the event that we receive an electronic request for additional information, this will be forwarded to you for completion. Please also notify us when the information was sent to the insurance by marking the date on the form sent to you and returning to us in your weekly submittal envelope.

We will keep the lines of communication open and will submit to you any requests or questions we may have.

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Revised: November 02, 2006

Invoices & Payment Instructions

After we have processed the last Submittal Envelope for any given month we will generate an invoice, on the first day of each month, based upon our contractual fees.

Billing Terms for All Clients

Payment and our receipt of all ChiliMBS invoices is expected in net 7 days, unless otherwise specified in your contract.

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Revised: November 02, 2006

Service Checklist & Instructions

This checklist is designed to take the guesswork out of your next step.

Return the completed Registration form & fee (if applicable)
Send a copy of the W-4 Forms for each provider on staff (employees)
Send a copy of the W-9 Forms for each Tax ID used
Send a list of participating carriers, if available
Send a copy of your current New Patient Information Form
Send a sample of your current Superbill/Treatment Form
Send a copy of the practice's Fee Schedule (procedural fees, as well as any in-house fees for missed appointments or cancellations, etc.).
Send your participating Insurance Carrier Billing Manuals and/or Guidelines, if available. (If your office does not have a copy of these manuals, we will request them for you).

Return ALL OF THE ABOVE FORMS to our office, including your registration fee (if applicable). Make checks payable to Chili Medical Billing Services. Once we receive your registration, any additional information requested, and we have a signed contract for services, we can begin filing your claims immediately. If there is missing information, we will notify your office immediately. If you have received a Customized Proposal, or other Fee Schedule, please attach a signed copy to this form.

If you find that you are in need of assistance when gathering the required information, please contact our office to request a "Data Capture Kit". The Data Capture Kit will walk you and your staff through the set up process, and allows us to set up your account in the most efficient manner, producing effective and informational management reports.

Once we have processed your registration, you will be receiving our standard Contract for Services and any EMC Agreements that a participating carrier may require when applying for your EMC rights. Please sign and return the original copies to Chili Medical Billing Services as quickly as possible, to prevent any delays in receiving EMC approvals. If you have any questions/concerns, please contact us at 585-889-7798.

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Please direct questions and/or comments to the Webmaster.
Revised: November 02, 2006