Account Receivables By Managed Care Plan

Please respond by Friday, December 9, 2016

In an effort to submit actual receivables data to NYSDOH on behalf of our members, please complete this short survey indicating you’re A/R by Managed Care Plan. Please fill out each blank with requested information and submit. This survey will close on Friday, December 9th.

Question Title

* 1. Facility Information:

Facility Name:

Address:

City:

Question Title

* 2. Please complete the following for each Medicaid Managed Care Plan (MLTC and / or MMC Medicaid Plan) your organization has an agreement with.

Plan #1 Name:

A/R 30 Days:

A/R 60 Days:

A/R 90 Days:

A/R 120 Days:

A/R over 120 Days:

Question Title

* 3. Please complete the following for each Medicaid Managed Care Plan (MLTC and / or MMC Medicaid Plan) your organization has an agreement with.

Plan #2 Name:

A/R 30 Days:

A/R 60 Days:

A/R 90 Days:

A/R 120 Days:

A/R over 120 Days:

Question Title

* 4. Please complete the following for each Medicaid Managed Care Plan (MLTC and / or MMC Medicaid Plan) your organization has an agreement with.

Plan #3 Name:

A/R 30 Days:

A/R 60 Days:

A/R 90 Days:

A/R 120 Days:

A/R over 120 Days:

Question Title

* 5. Please complete the following for each Medicaid Managed Care Plan (MLTC and / or MMC Medicaid Plan) your organization has an agreement with.

Plan #4 Name:

A/R 30 Days:

A/R 60 Days:

A/R 90 Days:

A/R 120 Days:

A/R over 120 Days:

Question Title

* 6. Please complete the following for each Medicaid Managed Care Plan (MLTC and / or MMC Medicaid Plan) your organization has an agreement with.

Plan #5 Name:

A/R 30 Days:

A/R 60 Days:

A/R 90 Days:

A/R 120 Days:

A/R over 120 Days:

Question Title

* 7. Above information was provided by:

Contact Name:

Title:

E-Mail Address:

Telephone:

Thank you for providing this important feedback as we continue to work with all stakeholders regarding managed care.