NSATA > Form Test Form Test Third Party Reimbursement Survey If you are human, leave this field blank. The following questions examine your practice setting. First Name * Last Name * City You Work In * Are you licensed to practice in Nebraska? * Yes No Do you have an NPI Number? * Yes No Are you a member of the NSATA? * Yes No The following questions are regarding basic demographic information in regards to your current employer. Name of your current Employer * 1. How many athletic trainers are employed by your current employer? * 1-3 4-6 7-10 >10 2. Does your employer allow autonomous billing by an athletic trainer? * Yes No 3. How many athletic trainers in your place of employment are actually autonomously billing for their services? * 1-3 4-6 7-10 >10 NA 4. Is your employer using the facility billing definition provided above? * Yes No NA 5. Which of the following forms is your employer using? * HCFA 1500 UB 04 Unsure NA 6. Which of the following CPT code(s) is your employer billing for? (Select all that apply) * 97169-97171 – Athletic Training evaluation (low complexity to high complexity) 97172 – Athletic Training re-evaluation 97110 – therapeutic exercise 97112 – neuromuscular re-education 97116 – gait training 97530 – therapeutic activities 96119 – neuropsychological testing (Paper) 96120 – neuropsychological testing (Computer) 97760 – orthotic/brace fitting NA OtherOther 7. Is your employer currently receiving reimbursement for the above AT services? * Yes No 7b. If yes, please identify which insurance companies (payors) have you been successful with: * State plans (i.e. NE Medicaid) State plans (i.e. NE Medicaid) Commercial plans (i.e. BC/BS)Commercial plans (i.e. BC/BS) Workers Compensation Workers Compensation OtherOther 8. Are you aware of any other employers within the state of Nebraska who are billing autonomously for AT services and being reimbursed? * No Yes (please identify):Yes (please identify): 9. Are you entered into the (Center for Affordable Quality Healthcare) CAQH database? * Yes No Unsure 10. A member of the NSATA 3rd Party Reimbursement Task Force may contact you if additional information or clarification is needed on the information you provided in this survey. Which would you prefer? (Select all that apply) * PhonePhone E-mailE-mail Submit
