Billing Discovery Form - TriumpHealth

Billing-Only Client Discovery Form

Purpose:

This form focuses on gathering information on existing billing operations, transition readiness, A/R, denials, reporting, and ongoing revenue-cycle support.

EHR/PM software, clearinghouse, payer portal access, and active payer enrollments are expected to be already established.

Instructions:

• Complete every applicable field. Select only services currently provided or planned.

• Upload supporting documents through the secure upload fields. Do not email protected or sensitive documents.

• Items marked “if applicable” may not apply to every provider or practice. Upload documentation through the secure portal only.

1. Client & Practice Information

Client Type *

Practice Name *

Full Legal Organization Name / DBA *

Tax Designation

Owner Name(s) and Ownership Percentage(s)

New or Established Practice

Practice Open / Planned Open Date

Practice Type / Setting

Specialty / Subspecialty

Number of Billing Providers

Number of Locations

States of Operation

Primary Service Area(s)

Website

2. Contacts & Communication

Primary Contact Name *

Primary Contact Title

Primary Contact Phone

Primary Contact Email *

Billing Contact

Credentialing Contact

IT / System Access Contact

Preferred Contact Method

Best Time to Contact

Escalation Contact

3. Addresses & Organization Identifiers

Physical Address(es) / Service Location(s) *

Billing Address

Mailing Address

Business Phone

Business Fax

Tax ID / EIN *

Group NPI *

Group Medicare PTAN

Group Medicaid ID(s)

Multiple TINs Used?

Additional Group NPIs or Billing Entities

CLIA Number

Facility License / Permit

4. Baseline Billing Volume & Current Status

Current Monthly Patient Volume

Current Monthly Encounters / Visits

Current Monthly Charges

Current Monthly Collections

Current A/R Balance

A/R Over 90 Days

Current Billing Model

Current Billing Vendor / Team Notes

5. Provider Information & Billing Roster

Add one record per billing or rendering provider.

Billing Type Options

6. Services Offered & Charge Capture

Describe Services Offered

Common Service Categories

Common CPT / HCPCS Codes Used

Common ICD-10 Diagnosis Categories

Modifiers Commonly Used

Place of Service Codes Used

Are Superbills or Charge Tickets Used?

Charge Entry Method

Who Reviews Charges Before Submission?

Charge Entry Deadline / Lag Time

Services Requiring Special Documentation

7. Existing Systems, Access & Connectivity

EHR / Practice Management System *

Billing Software

Clearinghouse

Patient Portal

Eligibility Tool

Payment Processing / Merchant System

Statement Vendor

Current Clearinghouse Payer IDs

EDI Enrollments Active?

ERA Enrollments Active?

EFT Enrollments Active?

Claims Submitted Electronically?

Reports Available from Current System

MFA / Access Requirements

Current Software or Billing Issues

8. Payers, Credentialing & Enrollment Status

Payers / Insurance Plans to Bill *

Provider Effective Dates Known?

Payer Portal Access Available?

Providers Pending Enrollment?

Payer-Specific Billing Rules or Carve-Outs

9. Current Billing Workflow & Transition

Describe the Current Billing Workflow

Who Verifies Eligibility?

Who Reviews Coding?

Who Handles Prior Authorizations?

Who Sends Patient Statements?

Who Takes Patient Billing Calls?

Biggest Priorities During Transition

Additional Notes, Payer-Specific Considerations, Special Billing Rules, Compliance Concerns, or Internal Handoff Notes

Secure Access & Document Uploads

Provider Roster and Demographic Files

Current A/R, Aging, Denial, and Financial Reports

Payer Contracts, Fee Schedules, and Enrollment Reports

EHR/PM, Clearinghouse, and Access Instructions

Charge Master, CPT List, Superbills, or Statement Templates

Client Authorization & Acknowledgment

Authorized Client Name *

Title *

Date *

TriumpHealth Intake Reviewer

Signature

✍ Draw Signature

⬆ Upload Signature

Use a mouse, touch screen, or stylus.

Upload Signature (PNG, JPG, or PDF)

I confirm that the information provided is accurate to the best of my knowledge and authorize TriumpHealth to use it for billing onboarding, claims-submission readiness, payer portal access, EDI/ERA/EFT coordination, A/R review, reporting, and related revenue-cycle support.

Disclaimer: Completion of this form does not guarantee payer approval, claim payment, reimbursement amount, collection outcome, or payer processing time. Sensitive documents must be uploaded only through the approved secure portal and should not be sent through unsecured email.

✓

Thank You — Your Billing-Only Discovery Form Has Been Submitted

Your information has been securely received for billing transition review.

Submission Reference:

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