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HIPAA Implementation Survey for Channel Partners and Direct Submitters

Please provide the following information.

(Fields marked with an * are required.)

Customer Information

Vendor Name * Fed Tax ID*
Aka/dba/fka Submitter ID*
Owner's Name Login ID*
Address * Communication
Method*
Address Ln 2  
City *    
State *    
Zip *    

Customer Contact Information

Executive Contact
Name Phone ext.
Title Fax
Email Address  
Operatonal Contact
Name* Phone* ext.
Title * Fax
Email Address *  
Technical Contact
Name* Phone* ext.
Title * Fax
Email Address *  
Telcom Contact
Name* Phone* ext.
Title * Fax
Email Address *  

EmdeonContact Information
Account Manager *

Summary of Request *

Customer Business Description

Commercial Government
Institutional Institutional
Professional Professional
Dental Dental
 
Total   % Electronic   % Through Emdeon
Claims per    
Encounters per    
ERA / ERT per    
Real-time per    

Requested Transaction Formats

Batch Services Current Format & Version Requested Format (Conversion)
Health Care Claim Institutional
[Claims or Encounters]
 HCDS v.

ASC X12N 835 v. 4010

ASC X12N v.
Other v.
Health Care Claim Professional
[Claims or Encounters]
 MCDS v.

ASC X12N 835 v. 4010

NSF v.
ASC X12N v.
Other v.
Health Care Claim Dental
[Claims or Encounters]
 DCDS v.

ASC X12N 835 v. 4010

ASC X12 v.
Other v.
Health Care Claim Payment/Advice
[ERA]
ASC X12N v. ASC X12N 835 v. 4010

Health Care Eligibility/Benefit Inquiry and Information Response ASC X12N v. ASC X12N 270 v. 4010

Health Care Claim Status Request and Response ASC X12N v. ASC X12N 276 v. 4010

Health Care Services Review -- Request for Review and Response
[Referral Pre-Cert and Authorization]
 ASC X12N v. ASC X12N 278 v. 4010

Health Care Services Review Inquiry/Response
[Referral Inquiry/Response]
 ASC X12N v. ASC X12N 278 v. 4010

Functional Acknowledgement 997   ASC X12N 994 v. 4010
997 Human Readable   997 Human Readable
None   None


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