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HELP Plan Uncollected Copayment Survey

3. Are you a professional provider or professional provider group?
  • If yes, provide information in the table below on each individual provider and then proceed to Question 5.
  • If no, proceed to Question 5.
4. If you answered yes to the previous question, please provide information in this table.
Space Cell Provider NPIProvider Last NameProvider First NameCredentials
1
2
3
4
5
6
7
8
9
10
5. Have you or any providers in your practice provided services to any Blue Cross and Blue Shield of Montana HELP Plan (TPA) participants during the timeframe July 1, 2016-June 30, 2017?  
  • If yes, go to question 6.
  • If no, stop and return the form.
6. Were any of the Blue Cross and Blue Shield of Montana HELP Plan (TPA) participants provided services between July 1, 2016-June 30, 2017 responsible for copayments.
  • If yes, go to question 7.
  • If no, stop and return the form.
7. For Blue Cross and Blue Shield of Montana HELP Plan (TPA) participants provided services between July 1, 2016-June 30, 2017 who were responsible for copayments, were you unable to collect any amounts due?  
  • If yes, go to Question 8.  
  • If no, stop and return the form.
9. For Blue Cross and Blue Shield of Montana HELP Plan (TPA) participants provided services between July 1, 2016-June 30, 2017 with uncollected copayments, what efforts were made to collect the amounts due?  
  • * This question is required.
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