:::NC Health Care Providers Alliance Informational Survey:::

NC Health Care Providers Alliance Informational Survey

Please complete the following survey. Comments and/or accompanying information are encouraged as this will assist us with
compiling data to help your company. Please use the narrative space below and attach additional pages if necessary. If you
have supporting documentation you may also fax that to our office at 336.794.4025.

Name of Company/Agency/Organization
Representative’s Name	Last Name
Title or Position
Area Code	Phone Number use numbers only!
Business Address
City
State/Region	Zip Code
Email Address
My company / organization is experiencing financial difficulties due to the recent decrease in authorization of services by Value Options.
My company / organization has either lost endorsement or have had to apply for re-instatement or file an appeal (with a local L.M.E. or D.M.H)
My company / organization has had to reduce, discontinue consumer services and/or reduce staff / employee positions within the past 2 to 6 months.
My company / organization has experienced over a 30% loss of consumers and revenue within the past 2 – 6 months.
My company /organization has experienced a Community Support (C.S.) audit and/or post payment review within the past 2 – 10 months.
My company / organization has been required to re-pay Medicaid (D.M.A) as a result of a C.S. audit and/or post payment review.
My company / organization has participated in a reconsideration hearing with the D.M.A. office relevant to a C.S. audit and/or post payment review.
My company / organization experienced C.S. paybacks due to the inability of Value Options to generate a timely authorization.
My company / organization has had monies withheld and/or garnished from their Medicaid payments without proper notification and/or verification.
My company / organization contracts with more than one L.M.E.
My company / organization has been required to adhere to varying and/or inconsistent endorsement / M.O.A. criteria (from one L.M.E. to another)
My company / organization has been offered and/or received “technical assistance” from the L.M.E. (or multiple L.M.E.’s) we are endorsed by.
*NOTE: If you have added supporting documents or additional pages,please list the total number. Email to :info@nchcpa.com or Fax to: 336-794-4025 Number of additional pages?	Check here ( Check the box if you will be sending us additional information) Please select how information will be sent. Email Fax Electronic Signature (Please type your Full Name)