CMS-10662 Compliance Review Program Triage Questionnaire Health Pl

Form Approved: OMB # 0938-1390

Expiration 12/31/2025

HHS Compliance Review Program

Triage Questionnaire

Health Plans

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 Health Plan¹ ☐ Business Associate

☐ Small Health Plan²

¹ Annual receipts > 5 million

² Annual receipts < $5 million (per regulation 45 CFR 160.103)

Health Plans - 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, 271 Health Care Eligibility Benefit Information Response
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, 277 Health Care Claim Status Response
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 Response
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 Remittance Advice 5010, 835 Health Care Claim Payment/Advice
Does your organization construct and/or transmit this transaction electronically to a trading partner?		☐ 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:

Coordination of Benefit (COB) Claim or Encounter 5010, 837 Health Care Claim - Institutional
Does your organization receive, process, and forward claims electronically to any trading partner (secondary or tertiary payers) for subsequent payment (COB)? 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:

Coordination of Benefit (COB) Claim or Encounter 5010, 837 Health Care Claim - Professional
Does your organization receive, process, and forward claims electronically to any trading partner (secondary or tertiary payers) for subsequent payment (COB)? 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:

Coordination of Benefit (COB) Claim or Encounter 5010, 837 Health Care Claim - Dental
Does your organization receive, process, and forward claims electronically to any trading partner (secondary or tertiary payers) for subsequent payment (COB)? 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:

Coordination of Benefit (COB) Claim or Encounter NCPDP D.0 Pharmacy Claim
Does your organization receive, process, and forward claims electronically to any trading partner (secondary or tertiary payers) for subsequent payment (COB)? 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 Plan Premium Payment 5010, 820 Premium Payment
Does your organization construct and/or transmit this transaction electronically to a trading partner?		☐ 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:

Enrollment and Disenrollment in a Health Plan 5010, 834 Health Care Benefits Enrollment and Maintenance
Does your organization construct and/or transmit this transaction electronically to a trading partner?		☐ 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.