Sevocity Database Request

Sevocity Database Request (New Practice Enrollment Form)

Clinic/Practice Name:*

Practice Tax ID:*

Group NPI:*

Practice Corporate Address *

Address Line 1

Address Line 2

City

State

ZIP Code

# of Billing Providers

Go Live Date - Important for EDI Enrollment

Go live is defined as the date live claims (encounters) are to be entered and billed. This date is very important for EDI paperwork. Some Insurance enrollments take 2-4 weeks (and if there are issues, up to 90 days) to process. An electronic data conversion will extend the time needed to Go Live. Please update EDI, right away, if this date changes.

City/State/Zips

We load city/state/zip cross reference codes. Specify which states you wish to have zip codes populated. We recommend asking for just ONE state when possible, to make look-ups easier to use with fewer results.

Charge Fee Schedule(s) - Do you want us to load a charge fee schedule?

Yes. We'll be providing a file. The file should be a CSV with these exact column titles( case sensitive): CPT Fee Modifier Yes, I want my charge fee created based on a percentage of the Medicare allowable amount. * see the next question for details No

If we are creating a Percentage Charge Fee Schedule

Please specify which state and locality you would like the fee schedule based on and what percent of Medicare you would like us to load (125%/150%/etc.).

State:

Locality:

Percentage:

Uploaded Forms:

Please provide forms, that would allow printing of pre-populated data out of Sevocity PM; fields such as patient name, DOB, etc. We can map two forms. Ideally this is something Sevocity stat. Check all that apply.

Charge Slip (Superbill)

File

No File Chosen

File uploads may not work on some mobile devices.

Patient Registration Sheet

File

No File Chosen

File uploads may not work on some mobile devices.

Other Forms

File

No File Chosen

File uploads may not work on some mobile devices.

EDI and Statement Enrollment Claims, ERAs and Eligibility

Electronic Claims & Remittance Enrollments

Some payers require enrollment to be able to submit claims electronically and/or to receive ERAs. Please ONLY check payers & states where your providers are credentialed and you see patients.

What lines of business do you need to enroll?

Professional (HCFA 1500 if billed on paper) Institutional (UB04 if billed on paper) BOTH Professional and Institutional

EDI (Claims) Enrollments:

BC/BS (Blues) Medicare DME RR Medicare Medicaid Tricare None: This client already uses Etactics as their clearinghouse

ERAs Currently Receiving?

It can change the ERA enrollment process if you are currently receiving ERAs from some payers. ERAs can only be received in one database ie either in their old PM or their new PM.

Eligibility?

Yes No

Turn on the Ability to check Eligibility (Real Time)

Eligibility Pricing

Per transaction Per provider

Eligibility for these payers?

Alliance for Health BCBS (Blues) Health Partners HealthSmart Kaiser Medicaid Tricare for You Tricare for Life

Other:

Eligibility top payers

If using Eligibility, please list the payers you are most interested in. If not using Eligibility, please enter N/A.

Additional Services

Additional Fees May Apply For Additional Services. See Print/Mail/eCorrect Addendum For More Details. eCorrect - Address Correction Service- The address is scrubbed at data entry, and scrubbed against the USPS DPV (Delivery Point Validation) database of valid addresses before mailing. This scrub is done to find problems that would include misspellings, incorrect abbreviations, bad formatting, and unknown addresses.

eDelivery

Yes No Maybe

Send bills to your patients electronically, thus drastically reducing your cost to mail. It includes the added benefit of verification that a bill was received. You are not required to handle or manage passwords with this solution. Mark only one oval.

ePay

Credit Card Payments Check Payments Company logo on website. (additional fee) Hyperlink from company website

Online Payment Service. Patients can update their address and insurance information, send the practice comments, view statements and make payments online. Ask your sales account executive for more details. NOTE: - a merchant service agreement is required with our integrated partner. Check all that apply.