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Note: Questions with an asterisk (*) require a response.

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* 1. What is the provider's name?

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* 2. What is the provider's license? (Choose all that apply.)

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* 3. What is the ZIP code of the provider's primary location?

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* 4. What is the provider's email address?

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* 5. Are you a BlueChoice® HealthPlan Healthy Blue Medicaid network provider?

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* 6. Are you a participating Medicare Advantage provider?

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* 7. Are you a CBA approved Telehealth provider?

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* 8. Utilization Management (UM)

  Always Usually Sometimes Never N/A
My Insurance Manager(SM) is a useful tool for claims filing and viewing remittances.
The CBA Form Resource Center is easy to use.
When an authorization denial is issued, the reason is clearly communicated.
UM staff members are helpful in addressing my questions or concerns.

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* 9. Do you use validated instruments and standardized questionnaires for assessments and monitoring?

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* 10. In the development of treatment plans, do you use evidence-based practices such as (check all that apply):

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* 11. Network Services

  Always Usually Sometimes Never N/A
Network services staff members are helpful in answering my questions.
In-person or virtual visits have been helpful.
Network Services staff return my calls or emails in a timely manner.

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* 12. Continuity and Coordination of Care

  Always Usually Sometimes Never N/A
I share information with my patients' other behavioral health providers for care coordination purposes with a signed release from the member.
I share information with my patients' family doctors for care coordination purposes with a signed release from the member.
I receive feedback from my patients' other behavioral health providers.
I receive feedback from my patients' family doctors.
I am satisfied with the level of communication between myself and other providers concerning the care of my patients.

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* 13. Appointment Availability

  Always Usually Sometimes Never N/A
I am able to schedule an established patient or refer to another provider emergency room within six hours for a non-life threatening emergency.
I am able to schedule an established patient or refer to another provider or emergency room within 48 hours for urgent care.
I am able to schedule an established patient for a routine outpatient visit within 10 working days.
I am able to schedule a follow-up visit for a new patient within 60 days of the initial visit.

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* 14. Please indicate your extended office hours. Choose all that apply.

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* 15. Are your normally available for quick access appointments?

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* 16. CBA's Website

  Always Usually Sometimes Never N/A
I access the CBA website at www.CompanionBenefitAlternatives.com.
I use the CBA website to download forms and other documents.
The CBA website is helpful in providing clinical and administrative information.

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* 17. I am aware that HEDIS quality standards state that a patient:

  Yes No
Should be seen by a behavioral health provider within seven days of discharge from an inpatient psychiatric admission.
With a depression diagnosis should have three follow-up visits within 12 weeks of the initial diagnosis.
With an attention deficit hyperactivity disorder (ADHD) diagnosis should have a follow-up visit with the prescriber within 30 days of beginning an ADHD medication.

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* 18. Overall Services

  Yes No
The overall services CBA provides are the same or better than those of other managed behavioral healthcare organizations (MBHOs).

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* 19. CBA will be developing a high-performance network. You may answer additional questions to determine your interest level in participating in a CBA high-performance network. Would you like to answer these additional questions?

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