CLAIM PROCESSING RISK ANALYSIS INFORMATION GATHERING FORM

OnPulse Billing Assistants

We help provide clarity and confidence to insurance navigation so you can focus on the important things. 

Your benefit analysis will include the discovery of insurance details and a personalized report of potential claim success and reimbursement.

OnPulse Billing Assistant Services May Include:
Primary Contact information:

Patient Information:

Insurance Information


Save & Return

Save your progress and complete this form later. (optional)


I am interested in billing and claims services for the following facility (facilities):
*Please include Facility name and Dates of service* *
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Diagnoses prompting admission or enrollment into the above facility (facilities):
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Did the patient have a referring provider who recommended enrollment/admission as medically necessary? *

Obtaining Coverage Details for Your Personalized Analysis
Our analysis of claim processing potential is free. In order to perform this free service, we must have detailed access to insurance coverage. 

You have 3 ways in which to provide access to your specific insurance coverage information:

1) Insurance web portal access
2) Providing plan documents
3) OnPulse call to your specified carrier

By granting insurance web portal access, you are receiving enhanced accuracy and efficiency for claims processing risks and potential for success.  Granting access to the web portal typically allows for a proficient review with concrete information. There is no cost to review your insurance coverage details through web portal access.  If you do not have a web portal but would like OnPulse representatives to create one on your behalf, please note the appropriate selection below. If you select this option, you will maintain ownership of your portal and have the right to change your password and login information at any time. 

If you are unwilling or unable to provide access, OnPulse Billing Assistants will perform a thorough review of your supplied plan documents in order to provide your free analysis. The cost for this plan document review service is $75. 

If you are unwilling or unable to provide access to your web portal or your specific plan documents, an OnPulse Billing Assistant must perform a call to your carrier to gain access to specific information utilizing specific verbiage. Cost for this service is $150 and must be performed in order to obtain your free analysis.

Please note: Web portals differ from carrier to carrier. While most carrier portals will provide sufficient information to perform thorough and efficient  reviews, this is not a 100% guarantee as insufficient details may be revealed once access is attained. We will provide details of insufficient information sourced should this event occur. At that time, you will be given the opportunity to supply plan documents or permit a carrier call with associated costs. 

Do you grant OnPulse web portal access? * 🛈


Current Total:
$0.00
Please provide payment information below:

Visa
By signing below, I acknowledge that I have read this agreement fully, understand its terms, and agree to them. 

I hereby authorize OnPulse to initiate debit and, if necessary, credit entries and adjustments for any debit entries in error.  I acknowledge that the authority will remain in effect until I have cancelled it in writing and that the origination of ACH transactions to my account must comply with the provisions of U.S. law.  I understand that if I choose a retainer service option or purchase additional services, the method of payment outlined above will be utilized unless I indicate otherwise in writing to finance@onpulse.com.

This authorization is to remain in full force and effect until OnPulse has received written notification from me of its termination in such time, and in such manner as to afford OnPulse and Financial Institution a reasonable opportunity to act on it.

Signature: *
clear
Our analysis includes a review of your benefit coverage so that we may advise on the risks associated with claims processing and rejection. Variables include but are not limited to whether or not your carrier provides out of network coverage and your current standing with deductibles. Beyond that, additional variables include medical necessity and authorization. OnPulse does its best to safeaguard your investment into our services by ensuring we've analyzed risk and enabled you to make the most educated decision to move foward in claim submission and processing. Due to above variables, claim processing services and cumulative amounts are not guaranteed. 
Chat: www.onpulse.com     Email: Hello@Onpulse.com     Call: 919-321-0300