ABA Practice Intake Form

Please fill out the following form to help us understand your ABA practice needs. This will allow our team to provide tailored credentialing, billing, and denial management support.

1. Practice & Contact Information

Practice Name:

Practice Owner or Main Contact Person:

Email Address:

Phone Number:

Location(s) of Service (City, State):

Time Zone:

2. Provider Information

Total number of BCBAs, RBTs, and other staff requiring credentialing:

Do you provide home-based, clinic-based, or telehealth services?

Do providers work as employees or independent contractors?

Are all providers enrolled in CAQH and have current attestation?

Do you currently have group NPI and individual NPIs established?

3. Credentialing Needs

Which payers do you want to enroll or maintain participation with?

Are there payers you are already credentialed with but need re-validation or updates?

Do you need help with ERA/EFT enrollment and tracking?

Any challenges with credentialing turnaround time in the past?

4. ABA Billing Information

Which billing software or EMR do you currently use?

What clearinghouse (if any) is integrated with your system?

Average weekly volume of claims submitted - if you are not sure provide the number of billable hours you provide a week:

Which billing codes are most frequently used (e.g., 97151, 97153, etc.)?

Are you billing primarily under:

Insurance (Commercial)
Medicaid (State: )
Private Pay

Do you bill under the rendering provider or supervising provider NPI?

How often do you submit claims (daily, weekly, etc.)?

Are you currently billing for telehealth sessions?

5. Denial & AR Management

Are there frequent denial reasons you encounter (e.g., lack of auth, provider not credentialed)?

Do you currently have a process for appeals and re-submissions?

What is your current average AR aging over 90 days?

Would you like assistance with:

Appeals & Resubmissions
Patient Balances/Statements
Medicaid Revalidations

Do you track and analyze claim denial trends currently?

6. Access & Workflow

Will our team have access to your EMR, billing system, and clearinghouse?

Preferred method for document sharing and claim file exchanges:

Google Drive
Dropbox
HIPAA-compliant email
EMR-integrated portal

Do you have any standard operating procedures (SOPs) or documentation we should follow?

7. Reporting & Communication

How often would you like to receive billing or AR reports:

Daily
Weekly
Bi-weekly
Monthly

Preferred communication method and frequency:

Specific KPIs you’d like us to include in reports (e.g., collection rate, AR days, denial rate):

8. Additional Notes

Please share any specific challenges, compliance concerns, or goals you have for your ABA billing and credentialing support: