CLIENT PROFILE FORM (for Denial Research Group / AppealMasters) YOUR FACILITY INFORMATIONFacility NameStreet AddressStreet Address 2CitySTZipMain PhoneMedicare Provider Number (NPI)TaxID#PTANSERVICES Appeal Outsourcing Onsite Appeal Training Veracity Client LEAD CONTACTNameTitleDepartmentE-mail PhoneBILLING INFORMATIONContact for Statements, A/RBilling ManagerE-mail Phone Use same address as above for billing Street AddressStreet Address 2CitySTZip Send Invoices to Lead Contact SYSTEM USERS (Non-Veracity Clients only)System Users are facility personnel that need access to Veracity for purposes of entering case information, uploading documents, or checking case status. User #1TitleDepartmentE-mailPhoneUser #2TitleDepartmentE-mailPhone Do you need additional users DOCUMENT / RECORDS MANAGERThe document manager is the default in Veracity for missing documents or record requests.NameE-mailPhoneDepartmentTitleHealth Records Vendor (if applicable)APPEAL INFORMATIONAPPEAL TYPEDenial / Audit TypesDenial / Audit Types Commercial Government IssuesIssues Medical Necessity Coding / DRG Validation Combination APPEAL VOLUME Occasional Bench Support Consistent Processing Solution Approximate ADR requests every 45 days? (gvt)Estimated number of cases to assign (monthly)Estimated number of cases to assign (monthly ) 0-10 10-25 25-50 50+ 100+ 200+ RECORDS AND DOCUMENTSMedical Record System File Naming Convention – Medical Record File Naming Convention – Demand Letter File Naming Convention – Review Results HANDLING YOUR APPEALSFacility to Vendor Notification ProcessFacility to Vendor Notification Process Assigned in Client Instance of Veracity Manually Entered in AppealMasters Veracity Fax E-mail To ensure timely submissions, AppealMasters will:To ensure timely submissions, AppealMasters will: Send Appeal via Secure Fax, Fedex/US Postal Service or Payer Portal Send Proof of Delivery to Payer (Commercial) Receive and Record All Decision Letters Send Demand Letter to Payer for untimely Response (Commercial) Receive and Respond to Notice of Hearing and Notify Facility Send Expedited Appeal to STOP RECOUPMENT (Gvt Appeals Only) Provide Weekly Report of Changes in Appeal Status ALJ APPEALSFacility Contact for Notice of ALJ HearingE-mail PhoneFacility Representative to be present for HearingList ALL attendees: Name & Title Other Special Instructions Thank you for completing our information form. We look forward to working with you! Please submit by clicking the button below.