CMS-10662 Compliance Review Program Triage Questionnaire Providers

Form Approved: OMB # 0938-1390

Expiration 12/31/2025

HHS Compliance Review Program

Triage Questionnaire

Providers

Section 1. Organization and Point of Contact Information

Organization Information
Organization Name:					Doing Business As:
Is your organization currently going through liquidation? ☐ Yes ☐ No
If yes, please describe the phase.
Contact Name:					Title:
Telephone:					E-mail:
Business Address:					City:
State/Province:			Country:				Zip:

Point of Contact Information
☐ Check if same as above
Organization Name:
Contact Name:				Title:
Telephone:				E-mail:
Business Address:				City:
State/Province:		Country:				Zip:

Section 2. Type of Covered Entity

Check All That Apply

☐ Large Provider¹ ☐ Business Associate

☐ Small Provider²

¹ Provider with more 25 or more full-time employees, or a physician, practitioner, facility, or supplier with 10 or more full-time equivalent employees

² Provider with less than 25 full time employees, or a physician, practitioner, facility, or supplier with less than 10 full time equivalent employees

Providers - Required HIPAA Covered Transactions:

For each transaction listed below, select the appropriate check box, and provide additional details as requested. A response is expected for each transaction type.

Eligibility Inquiry for a Health Plan 5010, 270 Health Care Eligibility Verification Request
Does your organization construct and/or transmit this transaction electronically to a trading partner?		☐ Yes ☐ No ☐ N/A
If YES: By what means?		☐ Real Time ☐ Batch
If NO: Has your organization ever been asked to provide this transaction electronically? In the space below, please provide an explanation as to why your organization does not construct and/or transmit this transaction to a trading partner.		☐ Yes ☐ No
If N/A: In the space below, please provide an explanation as to why your organization is not required to construct and or transmit this transaction to a trading partner.
Does another company or entity construct and/or transmit this transaction on behalf of your organization?		☐ Yes ☐ No
If Yes: Please provide the company or entity name:

Health Care Claim Status 5010, 276 Health Care Claim Status Request
Does your organization construct and/or transmit this transaction electronically to a trading partner?		☐ Yes ☐ No ☐ N/A
If YES: By what means?		☐ Real Time ☐ Batch
If NO: Has your organization ever been asked to provide this transaction electronically? In the space below, please provide an explanation as to why your organization does not construct and/or transmit this transaction to a trading partner.		☐ Yes ☐ No
If N/A: In the space below, please provide an explanation as to why your organization is not required to construct and or transmit this transaction to a trading partner.
Does another company or entity construct and/or transmit this transaction on behalf of your organization?		☐ Yes ☐ No
If Yes: Please provide the company or entity name:

Referral Certification and Authorization 5010, 278 Health Care Services Review Request
Does your organization construct and/or transmit this transaction electronically to a trading partner?		☐ Yes ☐ No ☐ N/A
If YES: By what means?		☐ Real Time ☐ Batch
If NO: Has your organization ever been asked to provide this transaction electronically? In the space below, please provide an explanation as to why your organization does not construct and/or transmit this transaction to a trading partner.		☐ Yes ☐ No
If N/A: In the space below, please provide an explanation as to why your organization is not required to construct and or transmit this transaction to a trading partner.
Does another company or entity construct and/or transmit this transaction on behalf of your organization?		☐ Yes ☐ No
If Yes: Please provide the company or entity name:

Health Care Claims or Equivalent Encounter Information 5010, 837 Health Care Claim - Institutional
Does your organization construct and/or transmit claims electronically to any trading partner? Or Does your organization transfer encounter information electronically?		☐ Yes ☐ No ☐ N/A
If NO: Has your organization ever been asked to provide this transaction electronically? In the space below, please provide an explanation as to why your organization does not construct and/or transmit this transaction to a trading partner.		☐ Yes ☐ No
If N/A: In the space below, please provide an explanation as to why your organization is not required to construct and or transmit this transaction to a trading partner.
Does another company or entity construct and/or transmit this transaction on behalf of your organization?		☐ Yes ☐ No
If Yes: Please provide the company or entity name:

Health Care Claims or Equivalent Encounter Information 5010, 837 Health Care Claim - Professional
Does your organization construct and/or transmit claims electronically to any trading partner? Or Does your organization transfer encounter information electronically?		☐ Yes ☐ No ☐ N/A
If NO: Has your organization ever been asked to provide this transaction electronically? In the space below, please provide an explanation as to why your organization does not construct and/or transmit this transaction to a trading partner.		☐ Yes ☐ No
If N/A: In the space below, please provide an explanation as to why your organization is not required to construct and or transmit this transaction to a trading partner.
Does another company or entity construct and/or transmit this transaction on behalf of your organization?		☐ Yes ☐ No
If Yes: Please provide the company or entity name:

Health Care Claims or Equivalent Encounter Information 5010, 837 Health Care Claim - Dental
Does your organization construct and/or transmit claims electronically to any trading partner? Or Does your organization transfer encounter information electronically?		☐ Yes ☐ No ☐ N/A
If NO: Has your organization ever been asked to provide this transaction electronically? In the space below, please provide an explanation as to why your organization does not construct and/or transmit this transaction to a trading partner.		☐ Yes ☐ No
If N/A: In the space below, please provide an explanation as to why your organization is not required to construct and or transmit this transaction to a trading partner.
Does another company or entity construct and/or transmit this transaction on behalf of your organization?		☐ Yes ☐ No
If Yes: Please provide the company or entity name:

Health Care Claims or Equivalent Encounter Information NCPDP D.0 Pharmacy Claim
Does your organization construct and/or transmit claims electronically to any trading partner? Or Does your organization transfer encounter information electronically?		☐ Yes ☐ No ☐ N/A
If NO: Has your organization ever been asked to provide this transaction electronically? In the space below, please provide an explanation as to why your organization does not construct and/or transmit this transaction to a trading partner.		☐ Yes ☐ No
If N/A: In the space below, please provide an explanation as to why your organization is not required to construct and or transmit this transaction to a trading partner.
Does another company or entity construct and/or transmit this transaction on behalf of your organization?		☐ Yes ☐ No
If Yes: Please provide the company or entity name:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1390 from the year of 2024 through 2025. The objective of the HIPAA Administrative Simplification information collection program is to conduct assessments and identify whether a covered entity is compliant with the HIPAA - adopted standards, and administrative simplification. The time required to complete this information collection is estimated to average less than 10 hours per response (4 forms x 60 minutes/form), including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is mandatory (under 45 CFR § 160.310) If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.