Thank you for registering and using this survey to submit your questions.

This session is an opportunity for AmeriHealth Caritas North Carolina staff to answer your questions about EVV. Please include as much detail as possible. If you do not know specific Claim #s, we must at least have the Member ID and Date of Service in order to research your inquiry. You will notice that these fields are not required because we recognize that you might have questions un-related to a specific claim. Use question 12 as an opportunity to tell us about the issues you are experiencing. Please note that if you do not fill in any information, we will not be able to research your inquiry in order to be prepared for the date of your session.

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* 1. Practice Name (Exa. ABC Pediatrics)

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* 2. Specialty

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* 3. Your Name (First and Last)

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* 4. Title

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* 5. Contact Information

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* 6. What date will you attend?

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* 7. Location TIN

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* 8. If applicable, Provider NPI

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* 9. Claim # (If you do not know, skip and include Member ID and Date of Service below).

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* 10. Member ID

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* 11. Date of Service for claim 

Date

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* 12. Please include any additional detail regarding the claim or issue you are experiencing. If you have filled in the previous questions #9-11, feel free to list N/A in this box to move forward and submit your registration.

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