Sign up for a Practice Review Information Request

We are looking forward to working with you on the Practice Review. This cover letter and the following form outlines the information request and processes necessary to get started. Please note the detail required for each of these areas and the need for the physical documents.

You can fax or scan or upload these documents as you gather them. It is best to send the information as you gather it, not trying to compile it all and send it through. This allows us to work on things as you are gathering the data. If you have any questions or need assistance, please contact us! We can help you.

Review Timeline

Set date and have a conference call to review the information request and address any questions.
Practice to assign a “Quarterback” for communication with OMS.
Complete Practice Information request form and send to OMS.
Scan and upload all required documents requested.
We will review and analyze data identifying any gaps in the data.
If needed, we will reach out to you to clarify our questions or need for additional information.

The fax number is 888-316-3118 and we will provide you a link to a shared folder to securely upload the data. The digital fax is routed to a secure email box. If you have any questions, please do not hesitate to contact us for assistance.

Practice Name(Required)

Website address(Required)

Primary Office

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Fax

Email(Required)

County

Secondary Office (If Applicable)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

County

Required Documentation for Practice Validation

Aged Insurance Accounts Receivable Report (Summary by insurance, no patient balances) Excel or .CSV format preferred.
Aged Patient Balance Accounts Receivable Report in Excel or .CSV format preferred.
CPT Production report for the past 12 months in Excel or .CSV format preferred (total only not monthly).
Clearinghouse Access – User name: Password:
Choose 10 Medical Records where claims were filed for medical eye care visits to medical insurance.
- Medical Record for the DOS (Date of Service). Must include exam details.
- Provide the HCFA 1500 claim form (printed version is acceptable) that was billed for the patient’s DOS provided. No need to print 1500 on an actual form, system generated form is acceptable.
- Provide the patient invoice matching the medical records DOS provided.
- EOB/ERAs for each record provided to show payments on claims filed (make sure DOS match).
1 EOB from each major insurance company (Medicare, Blue Cross/Anthem, United Health Care, Aetna, Humana, TriCare, Cigna, VSP, EyeMed, Optum, etc).
Contact information for person that can explain billing process. We will set up a phone call with this individual to review the current billing and AR processes.