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Audit Pre-Screening Questionnaire








  
  
    

  
      



**Audit Pre-Screening Questionnaire Instructions:**

The questionnaire is made up of 4 parts: Instructions, Contact/Entity Info, Questions, Review & Submit.

If you are unable to complete the questionnaire in its entirety, you can [SAVE] your responses and complete the questionnaire at a later time using the link that was provided in the email notification. Once [Submit] has been selected, you will not be able to re-access the questionnaire.

**Contact/Entity Type** – Please review and update as needed. All fields are required. If all fields are not completed before clicking [Continue] or the Questionnaire tab the system will display at the top of the screen a list of the missing information.

**Questionnaire** – A response is required for all questions. If all fields are not completed before clicking [Review and Submit] the system will display at the top of the screen a list of the missing information.

**Review & Submit** – The system will display all questions with your responses. Scroll to the bottom to select [Print] to retain a copy of your responses. To change a response, click the Questionnaire tab at the top of the screen. Click [Submit] to submit your responses. Once submitted, access to the questionnaire is no longer available.

Questions:

Basic Description Information About Your Organization

**Question 1:**

**Answer Choices:**

Public
	Private**Question 2:** Entity is:

**Answer Choices:**

Single location only (the primary operations and any support activities are co-located)
	Multi-location (the organization has multiple service delivery sites and/or separate support facilities)**Question 3:** Is your organization part of, affiliated with, or otherwise owned or controlled by another organization?

**Answer Choices:**

No
	Yes**Question 4:** If your organization is a part of, affiliated with, or otherwise owned or controlled by another organization, identify the organization and describe the relationship to your entity: (If your answer to #3 is “No”, enter N/A for the relationship and organization)

**Answer Choices:**

Nature of relationship
	Name of other organizationHealthcare Providers

**Question 5:** Are you a HIPAA covered entity?

**Answer Choices:**

Yes
	No**Question 6:** Does your organization or another entity on your behalf, conduct health care transactions (such as submitting a claim for payment, checking patient health plan eligibility or benefit coverage, or receipt of payment or remittance advice) in electronic form?

**Answer Choices:**

Yes
	No**Question 7:** What type of health care provider are you (hospital, urgent care, skilled nursing, etc.)?

**Answer Choices:**

**Question 8:** How many patient visits in the prior fiscal year?

**Answer Choices:**

**Question 9:** How many patient beds do you have (if applicable)?

**Answer Choices:**

**Question 10:** What is the current number of clinicians on staff or with privileges in the facility(ies)?

**Answer Choices:**

**Question 11:** Do you maintain or transmit protected health information in electronic format?

**Answer Choices:**

Yes
	No**Question 12:** Do you use electronic medical records?

**Answer Choices:**

Yes
	No**Question 13:** What is the total revenue for the most recent fiscal year?

**Answer Choices:**

Health Plans

**Question 14:** Are you a Group Health Plan sponsor responding on its behalf?

**Answer Choices:**

Yes
	No**Question 15:** What is the total number of members within your health plan(s)?

**Answer Choices:**

**Question 16:** What is the average number of claims processed monthly in the most recent fiscal year?

**Answer Choices:**

**Question 17:** What is the total revenue for the most recent fiscal year?

**Answer Choices:**

**Question 18:** Do you utilize a third party administrator (TPA) or other entity to perform most of the health plan functions?

**Answer Choices:**

No
	Yes (Note: Selecting “Yes” will require you to supply the following information: “If yes, please provide the name, address, email address, phone number, an alternate contact and an appropriate contact person at the TPA or other entity (e.g., health insurance issuer or HMO):”)**Question 19:** If you are a group health plan sponsor, do you receive only summary data from the group health plan, health insurance issuer, or HMO?

**Answer Choices:**

Yes
	No
	N/AHealthcare Clearinghouse

**Question 20:** What is the total number of transactions processed monthly in the most recent fiscal year?

**Answer Choices:**

**Question 21**: What is the current number of healthcare providers, health plans, and other entities served?

**Answer Choices:**

**Question 22:** What is the total revenue for the most recent fiscal year?

**Answer Choices:**

**Question 23:** Do you operate only as a business associate and do not maintain protected health information or perform covered functions as a covered entity apart from your activities as a business associate?

**Answer Choices:**

Business Associates

**Question 24:** Please briefly describe the nature of your business associate activities (e.g., billing, third party administrator, information technology support, legal services, etc.).

**Answer Choices:**

**Question 25:** Identify the type(s) of covered entity(ies) for which you provide business associate functions (choose all that apply).

**Answer Choices:**

Health Care Provider
	Health Plan
	Heath Care Clearinghouse**Question 26:**Identify whether any of the covered entity(ies) for which you provide business associate functions are Organized Health Care Arrangements (OHCA) or Affiliated Covered Entities (ACE) (choose all that apply).

**Answer Choices:**

OHCA
	ACE
	Neither
	Not sure**Question 27:** Identify the approximate number of each type of covered entity for which you provide business associate functions: (please indicate a number for each option selected): NOTE: If you provide business associate functions for OHCA’s or ACE’s, please add the component covered entities separately into the totals below. For example, if you are a business associate to an OCHA comprised of 10 covered providers, add 10 to the covered provider total option below)

**Answer Choices:**

Health Care Provider
	Health Plan
	Health Care Clearinghouse**Question 28:**Do your business associate activities involve maintaining or transmitting protected health information in electronic form?

**Answer Choices:**

Yes
	No**Question 29:** Do you perform business associate functions in more than one state?

**Answer Choices:**

**Question 30:** What is the approximate total revenue from all of your business associate activities in the most recent fiscal year?

**Answer Choices:**

                    
  


Content created by Office for Civil Rights (OCR) Content last reviewed December 23, 2022Back to top
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