Healthcents’ DME OrganizationQuestionnaire

  1. Legal Name of the DME organization:
  1. DBA?
  1. What company name will the insurance contracts be using for contracting purposes?
  1. Company Tax ID and NPI for contracting purposes?
  1. How many years has the DME organization been open for business?
  1. Please describe the ownership structure of the organization. How many owners? What percentage does each owner have? Who is responsible for reviewing and signing contracts with Insurance companies?
  1. What are the physical address of all affiliated offices?
  1. Is each affiliated office Medicare Certified? JCAHO accredited?
  1. What is the billing/remit address for each office?
  1. Will all offices be billing under the same TIN? If not, please list offices, NPI and TIN for each office.
  1. Is the company part of any clinically integrated organizations, such as ACOs or IPAs?
  2. Arethere any special products that you provide that are not available by any other DME organization in town?
  3. What delineates you from your competition? (i.e.- what makes your facility special/unique in your market? Services?Qualifications? Credentials? Research?)Please explain why you feel that your DME organization is the best facilityacross the country. What are the competitive benefits of your DME organization compared to others in the area/country?
  4. Are the referring physician group / owners currently in the payor(s) provider / physician network? If so, which lines of business (PPO / HMO / WC / Auto)?
  5. Which contracts are you most interested in and in what sequence?
  1. Name, address, email and phone number of your provider relations contact for each payer and / or contracts manager, if you have one
  1. Revenue per year and number of patients by Payer. The total only collected from each payer for a 12 month period, not the claims details or individual records.
  1. Electronic logo, company letter head

Additional Notes/Comments: Please provide any additional data or information that you believe will be important to payer organizations when reviewing your request for network participation.

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