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Client Onboarding
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Getting Started
This form collects the information needed to set up billing and revenue-cycle services for your pharmacy. Please keep a copy of the confirmation email you receive. You can leave at any time and resume from a link we email you.
Email for form link & signed document
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Section 1 — Pharmacy & Business Information
Legal Business Name
*
DBA / Pharmacy Name
*
Tax ID / EIN
Format: XX-XXXXXXX
NPI (National Provider Identifier)
Format: 10 digits
NCPDP Number
Format: 7 digits
NABP Number
Format: 7 digits
Pharmacy License Number(s)
State(s) Licensed
Primary Pharmacy Address
Website
Main Telephone
Fax
General Email
Pharmacy Type (check all that apply)
Retail / Community
Hospital-Owned
Specialty
Clinic / Physician-Owned
Compounding
Infusion
Long-Term Care (LTC)
DME / Medical Supplies
Mail Order
340B
Independent
Other:
Additional Location Information
Add a row per additional location.
Location Name
Physical Address
NCPDP Number
State License Number
×
+ Add row
Add a row per additional location.
Section 2 — Ownership & Key Contacts
Provide contact information for each of the core roles below. Passwords must NOT be provided on this form.
Designated Contact Roles
Role
Full Name
Title / License (e.g. PharmD, RPh, CFO)
Direct Phone
Email Address
Role
Full Name
Title / License (e.g. PharmD, RPh, CFO)
Direct Phone
Email Address
Role
Full Name
Title / License (e.g. PharmD, RPh, CFO)
Direct Phone
Email Address
Role
Full Name
Title / License (e.g. PharmD, RPh, CFO)
Direct Phone
Email Address
Role
Full Name
Title / License (e.g. PharmD, RPh, CFO)
Direct Phone
Email Address
Role
Full Name
Title / License (e.g. PharmD, RPh, CFO)
Direct Phone
Email Address
+ Add row
Section 3 — Services to Be Provided
Pharmacy Claims & Billing (check all that apply)
Prescription claim submission
Secondary billing
Third-party insurance billing
Rebilling / corrected claims
Medicare Part claims
Claim rejection management
Medicaid claims
Reversals
Commercial payer claims
Claim denial management
PBM claims
Prior authorization support
Workers’ compensation
Eligibility verification
Auto insurance
Coverage investigation
Coordination of benefits (COB)
Other:
Accounts Receivable / Follow-Up
Insurance A/R follow-up
Denial follow-up
Underpayment review
Overpayment review
Unpaid claim follow-up
Reconciliation
Other:
Financial / Reporting Services
Daily billing reports
Weekly reports
Monthly A/R reports
Payer performance reporting
Rejection reporting
Denial reporting
Payment reconciliation
Revenue trend reporting
Other:
Additional Services
Credentialing
NCPDP enrollment support
Payer enrollment
Medicare enrollment
Medicaid enrollment
PBM enrollment
DME billing
CAQH management
Medical billing
Consulting
340B billing support
Other:
Section 4 — Pharmacy Operations
Average prescriptions filled per day
Average prescriptions filled per month
Average paid claims per month
Average rejected claims per month
Average reversed claims per month
Average cash-pay prescriptions per month
Number of pharmacists on staff
Number of pharmacy technicians
Number of billing / administrative staff
Hours of Operation (Monday through Sunday)
Section 5 — PBM / Switch / Claim Submission
Primary Claim Switch / Clearinghouse
Secondary Switch / Clearinghouse
Who currently submits pharmacy claims?
Are claims submitted electronically?
Yes
No
Are claims submitted in real time?
Yes
No
Who currently manages rejected claims?
Who currently manages unpaid claims?
Section 6 — Payer Portals & Online Access
SECURITY NOTICE: Do not write passwords on this form. Secure credentials should be transferred through the agreed secure method.
Portal Access Details
Portal Name / URL
Username / User ID
Access Contact Person
MFA Required?
Access Needed?
×
+ Add row
Section 7 — Enrollment & Credentialing
Medicare Part D Enrollment Status
Medicaid State & Enrollment Status
Commercial / PBM Enrollment Status
Are copies of payer contracts available?
Yes
No
Are reimbursement schedules available?
Yes
No
Are Maximum Allowable Cost (MAC) pricing schedules available?
Yes
No
Section 8 — 340B Information
Does the pharmacy participate in a 340B program?
Yes
No
340B Covered Entity Name
340B ID Number
340B Administrator / Software Provider
Current 340B Billing Process Description
340B Reporting Requirements
340B Primary Contact Person
Section 9 — DME / Medical Billing
Does the pharmacy bill medical insurance for any products or services?
Yes
No
Select categories billed
Durable Medical Equipment (DME)
Diabetic supplies
Continuous Glucose Monitors (CGM)
Infusion supplies
Wound care supplies
Compression garments
Ostomy supplies
Incontinence supplies
Medical supplies
Pharmacy-administered drugs
Other:
Medical Billing Software
Medical Billing Clearinghouse
Current CPT / HCPCS Billing Process
Current DME Enrollment Status
Section 10 — Current Billing Performance
Average Monthly Gross Billed Amount
Average Monthly Insurance Payments Received
Average Monthly Patient Payments Received
Average Monthly Claim Reversals Amount
Average Monthly Rejected Claims Value
Average Monthly Denied / Unpaid Claims Value
Average Monthly Billing Adjustments
Current Total Accounts Receivable (A/R) Balance
Estimated Current Clean Claim Rate
Aged Accounts Receivable Breakdown
A/R Balance 0 – 30 Days
A/R Balance 31 – 60 Days
A/R Balance 61 – 90 Days
A/R Balance 91 – 120+ Days
Section 11 — Common Claim Rejections & Denials
Common Rejection Reasons (check all that apply)
Prior authorization required
Patient eligibility expired / invalid
Refill too soon
Quantity limitation exceeded
Non-covered drug
Drug not on formulary
Invalid member ID
Invalid BIN / PCN
Coordination of benefits required
Pharmacy not contracted
Prescriber not enrolled / invalid NPI
NDC issue / obsolete drug
DAW code issue
Drug Utilization Review (DUR) rejection
Pricing / cost issue
MAC price dispute
Duplicate claim
Compound claim issue
Timely filing limit exceeded
Other:
Top Rejection / Denial Problems
Ranking
Rejection / Denial Problem
Ranking
Rejection / Denial Problem
Ranking
Rejection / Denial Problem
Ranking
Rejection / Denial Problem
Ranking
Rejection / Denial Problem
+ Add row
Section 12 — Prior Authorization & Coverage Support
Does the pharmacy currently assist with prior authorizations?
Yes
No
Who handles the prior authorization workflow?
Does the pharmacy perform benefits investigations?
Yes
No
Does the pharmacy assist with manufacturer copay assistance?
Yes
No
Does the pharmacy work with specialty medication manufacturers?
Yes
No
Section 13 — Software & Technology
Pharmacy Management System (PMS)
Billing System
Accounting System
Electronic Payment / ERA System
Clearinghouse / Switch Provider
Other Operational Software
Operational Integrations (check all that apply)
Pharmacy software → Switch
Pharmacy software → Clearinghouse
Pharmacy software → Accounting
ERA → Billing system
Switch → PBM
Other:
Section 14 — Reporting Requirements
Desired Reports (check all that apply)
Daily claim report
Rejection report
Denial report
A/R aging report
Payment report
Revenue report
Payer performance report
Prescription volume report
Specialty revenue report
340B report
DME report
Other:
Report Frequency
Daily
Weekly
Monthly
Custom
Additional Reporting Requirements
Section 15 — Compliance & Security
Regulatory & Security Compliance (check all that apply)
HIPAA Compliance
PCI DSS Compliance
Medicare Compliance
340B Compliance
Medicaid Requirements
PBM Contractual Requirements
State-Specific Pharmacy Board Requirements
Other:
Does the pharmacy have a HIPAA Business Associate Agreement (BAA) process?
Yes
No
Section 16 — Access & Authorization
SECURITY NOTICE: Do not provide passwords on this form. Use client-created individual users, portal invitations, or another secure access method.
Section 17 — Client Expectations & Goals
Strategic Goals (check all that apply)
Increase revenue collections
Reduce claim rejections
Reduce claim denials
Reduce outstanding A/R
Improve cash flow cycle
Improve payment posting accuracy
Improve payer follow-up frequency
Improve reporting visibility
Reduce administrative workload
Improve reimbursement rates
Identify underpayments
Improve claim turnaround time
Other:
Section 18 — Implementation & Communication
Preferred Go-Live Date
Preferred Billing Cutover Date
Preferred Meeting Frequency
Preferred Communication Method
Primary Client Decision Maker
Backup Operational Contact
Section 19 — Client Attestation
I certify that the information provided in this onboarding form is accurate and complete to the best of my knowledge. I understand that incomplete or inaccurate information may delay implementation or affect billing and revenue cycle performance.
Authorized Representative Name
*
Official Title
*
Signature
*
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